Enhancing Motivation to
Change
Developed by DATA of Rhode Island
Through a special grant from the Rhode Island
Department of Human Services
September 2006
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Motivational Interviewing
has been successfully used to assist
people with a variety of problems:
•Alcohol Abuse
•Drug Abuse
•Dual Diagnosis
•Diabetes
•Gambling
•Mental Health
•Smoking
•Cardiovascular Health
•Eating Disorders
•Health Promotion
•HIV Risk
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The Goal of Today’s
Training is:
For trainees to learn about:
stages of readiness to change
motivational interviewing (MI)
how to utilize MI techniques to more effectively assist
people to make life changes in a variety of areas
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Group Discussion Questions:
Why don’t People Change?
1.
2.
3.
4.
5.
6.
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
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Group Discussion Questions:
Why do People Change?
1.
2.
3.
4.
5.
6.
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
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Motivational Interviewing:
Readiness to Change
4 possible change options:
1. Not ready
2. Unsure
3. Ready
4. Trying
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The Goal of MI:
To Assist People to Become
Ready, Willing, and Able
Willing: The Importance of Change
Able: Confidence for Change
Ready: A Matter of Priorities
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What Motivates Change?
Self questioning
Values
Needs
Readiness
Anxieties
Insight
Desire
Discovery
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Motivational Interviewing
A Definition – Bill Miller, PhD
Motivational interviewing is a
 person-centered
 directive method of communication
 for enhancing intrinsic motivation to change
by exploring and resolving ambivalence
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Four Basic MI Skills: OARS
Ask OPEN questions



not short-answer
yes/no
rhetorical questions
AFFIRM the person

comment positively on strengths,
effort, intention,
REFLECT what the person
says

"active listening“
SUMMARIZE

draw together the person's own
perspectives on change
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Open/Closed Questions
Formulate Open and Closed Q’s regarding:




About changing (i.e., smoking, diet, exercise, etc.)
About what may happen in the future (without change, with change)
About the negative consequences already experienced
About the differences in _________ between now & then
Confidence

About changing (i.e., smoking, diet, exercise, etc.)
Importance




About what may happen in the future (without change, with change)
About coping with temptation
About maintaining motivation
About what could be of help to you
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Stages of Change Model
Maintenance
Precontemplation
Relapse
Action
Contemplation
Preparation Determination
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Stages of Change
Pre-contemplation
Contemplation
Preparation/Determination
Action
Maintenance
Relapse
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PRE-CONTEMPLATION
No intention of
“Who, me?”
changing target
No consideration to
change
Lack of motivation
to change
Low self-efficacy
Lack of information
Contentment with
status quo
behavior
No action toward
change
Engages in targeted
behavior freely
Does not connect life
difficulties to the
behavior
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Precontemplation
Client
1 Person is not yet
considering the
possibility of
change.
2 Person does not
actively pursue
treatment.
Helper
a Helper needs to
provide information
and personalized
feedback in order to
increase client’s
awareness.
b Giving advice is
counterproductive
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A Typical Day
A. Explain the purpose & define a time-frame
 Can we spend the next few minutes talking about
______so that I can better understand how it fits
into your everyday life?
B. Locate the day/session to be described
 Think of a typical recent day (time) which would
give me a good picture of how you use ___. Can
you think of one?
C. Ask for a detailed description
 I’d like you to take me through this day, a step at
a time and tell me how _____ fits into the day.
You woke up at _____?
D. Follow the person’s statements with open-ended
questions and short summaries
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Core Value Discrepancy
Which of the following values, traits, or
characteristics are important to you?
good parent
good
spouse/partner
god community
member
strong
on top of things
competent
spiritual
respected @ home
good Christian,
Jew, Moslem, etc.
attractive
disciplined
responsible
in control
respected by others
athletic
organized
energetic
compassionate
dependable
honest
open-minded
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Core Value Discrepancy
How, if at all, is your current behavior related to
these?
How, if at all, does your current behavior affect your
ability to achieve these goals or live out these values?
I’m curious…..

Do you see a connection between your ____ behavior and
any of these values/goals?
I’m curious…..


Do you see a connection between your health and any of
these values/goals?
Do you see any connection between your ___ behavior and
your health?
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Readiness Ruler
“How important is it for you to change?”
How confident are you that you could change if
you decided to?”
1
2
Not Ready
3
4
5
Unsure
6
7
8
9
10
Ready
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CONTEMPLATION
“yes, but”
To Change
Not to Change
Highly ambivalent
Waivers
considerably;
ponders change
than rejects it
“Yes-but”
rationalizations
Low intention to
change & no
sustained action
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Ambivalence is the Issue To change
Not to Change
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Contemplation
Client
1 Person is
ambivalent about
change.
2 Client might bring
up the issue or ask
for assistance.
Helper
a. Aim is to tip the balance
in favor of change.
b. Elicit reasons for change
c. Strengthen client’s
confidence
d. Help assess reasons for
and against change
e. Action steps will most
likely be met with
resistance.
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The Good and Not So Good
“ I’d like to understand the role _____ plays in your
life”
Always start with the good


What are some of the good things about _______?
What do you like about _______?
When the list is obtained offer a summary.
Remain neutral in query for not so good (don’t
assume not so good = bad)


What are some of the less good things about _______?
What about the other side. What’s the not so good side of
_________?
Use opened ended questions to find out why the
person thinks these things are “less good”
Offer a summary statement as succinctly as possible
Thank the client for their assistance.
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Decisional Balance Sheet
Reasons for staying the same
Good things about:
1.
2.
3.
Not so good things about
changing:
1.
2.
3.
Reasons for making a change
Not so good things
about:
1.
2.
3.
Good things about
changing:
1.
2.
3.
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PREPARATION
“uh-oh”
Commitment to act
Internal motivation replacing
external motivation
Window of opportunity
Risk taking
Serious intention to change
Moving towards action, but still not
sustained
Recognizes that change must
occur, but not sure how
May not believe change must be
permanent
Need to assess:



FEARS
BARRIERS
STRENGTHS
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Preparation/Determination
Client
Helper
1. A window of
a. Help the client strengthen
opportunity that
commitment and motivation
opens for a period
for change.
of time.
b. Help client find a strategy
2. Person may be
that is acceptable,
modifying current
accessible and effective
behavior in
c. May be met with resistance
preparation for
future change.
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Scaling Questions
☻ How IMPORTANT is it for you to change right now?
On a scale of 0 to 10, what number would you give yourself?
0---------------------------5----------------------10
not at all important
extremely important
a. Why are you at X and not 1?
b. What would need to happen for you to get from X to Y?
c. How can I help you get from X to Y?
☺ If you decided to change, how CONFIDENT are you
that you could do it?
On a scale of 0 to 10, what number would you give yourself?
0---------------------------5-----------------------10
not at all confident
extremely confident
a. Why are you at X and not 1?
b. What would need to happen for you to get from X to Y?
c. How can I help you get from X to Y?
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ASK Key Questions
“So, what’s next?”
There’s no ‘right” road that works
for everybody. I can try to help
you figure out what might works
for you.”
“Where do we go from here?”
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End of Section 1
BREAK
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Signs of Readiness to
Change
Decreased Resistance
Lots of change talk
Envisioning the future
Questions about changing
Experimenting with small change
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Negotiate Achievable Goals
Offer a MENU of options



Avoid jargon
Start with simplest strategies [baby steps]
Use language the client understands
AGREE on a next step


Which option seems the most reasonable?
“Do you feel ready to act on may of these
choices?”
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ACTION --- “do it”
Change is
occurring
Goal directed
Respond to
challenges
Experimentation
Skill building
Takes clearly
identifiable steps
toward change
Efforts are
sustained despite
setbacks
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Action
Client
1. Person engages in
actions intended to
bring about change.
2. Change areas are
client specific and
include: attitude,
behavior, thoughts
and feelings.
Helper
Affirm commitment to
change.
Help identify
necessary steps for
change.
Identify additional
resources.
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MAINTENANCE –
“Living life on life’s terms”
Maintain change for a significant
time period (6 mo.)
Focuses efforts on preventing
relapse & developing the
capacity to live a recovery
lifestyle
Re-evaluation
Long-term goals
New skills
Open to feedback
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RELAPSE
“back to the drawing board”
Recurrence
Cope with the
consequences
Avoid becoming
demoralized
Decide what to do next
Renew process of
contemplation
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Relapse/Recycling
Client
1. Has returned to
previous behavior.
2. May occur in any
stage.
3. Client may feel like
a failure and be
discouraged about
ability to change.
Helper
a. Assure client that slips
may happen.
b. Help client avoid
becoming discouraged
and demoralized.
c. Help client renew
determination and
confidence to resume
change efforts.
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Motivational Interviewing and
Motivational Enhancement
 Uses helper skills to elicit statements from
client about goals, desires, motivation levels;
 Acknowledges stages of change and
differential levels of motivation through which
individuals typically pass (and may return,
over and over again);
 Advocates that helpers “roll with resistance”
and reinforce client movement and attempts
toward change.
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What is Motivational
Interviewing?
Listening with empathetic
understanding
Evoking client’s own concerns &
motivations
Avoiding argument for change
Nurturing hope & optimism
Eliciting & shaping client language
toward adaptive change
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What Motivational Interviewing
is Not:
Giving information
Giving advice
Using logic to persuade
Warning
Confronting
Agreeing
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Four General Principles of MI
1.
2.
3.
4.
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy
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1. Express Empathy
Acceptance facilitates change
Skillful reflective listening is fundamental
Ambivalence is normal
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2. Develop Discrepancy
The person rather than the
counselor should present the
arguments for change
Change is motivated by a
perceived discrepancy between
present behavior and important
personal goals or values
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Roll with Resistance
Avoid arguing for change
Resistance is not directly opposed
New perspectives are invited, not
imposed
Resistance is a signal to respond
differently
The person is a primary resource
in finding answers and solutions
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Support Self-Efficacy
A person’s belief in the possibility
of change is an important
motivator
The person, 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
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Five MI Methods
1.
2.
3.
4.
5.
Ask Open Questions
Listen Reflectively
Affirm
Summarize
Elicit Change Talk
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1. Ask Open Ended
Questions
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2. Listen Reflectively
Avoid roadblocks
Think reflectively (hypothesis
testing)
A statement, not a question
Levels of reflection
Understating and overstating
Continuing the paragraph
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3. Affirm
Provide ‘attaboys' & 'attagirls'
Acknowledge difficulty of seeking
assistance, considering change, making
change, & sustaining change
Focus on & reinforce successes
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4. Summarize
Collecting Summary
Linking Summary
Transitional Summary
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5. Elicit Change Talk
Asking Evocative Questions
Using The Importance Ruler
Exploring the Decisional Balance
Elaborating
Querying Extremes
Looking Back / Looking Forward
Exploring Goals and Values
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Goals for Effective MI
Talk less than the client does
Reflect twice for every question asked
(2:1 ratio)
Ask mostly opened questions (OEQS)
Avoid getting ahead of the client’s
change readiness (helper offering
change talk or unsolicited advice)
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Demonstration
MI in Practice
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Discussion of Demonstration
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Questions?
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Closing Exercise
1.
Something I liked?
2.
Something I’ll use?
3.
This training will help me?
4.
Something more I wanted more of?
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Suggested Articles or Readings
Miller, W. & Rollnick, S. (2002). Motivational Interviewing:
Preparing People for Change. 2nd edition. NYC, NY:
Guilford Press.
Prochaska, J., Norcross, J. & DiClemente, C. (1994).
Changing for Good. NYC, NY: Avon Books.
SAMHSA. (2002) TIP Manual 35: Enhancing Motivation for
Change in Substance Abuse Treatment. Washington,
DC: SAMHSA (US Government Document)
SAMHSA. (1999). Quick Guide for Clinicians Based on TIP
Manual 35: Enhancing Motivation for Change in
Substance Abuse Treatment. Washington, DC: SAMHSA
(US Government Document)
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Suggested Websites
www. motivationalinterview.org
www.casa.unm.edu
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