Welcome to…
Motivational Interviewing for
HIV/AIDS Prevention Programs
For Bringing Hope (BH) and Abstinence & Be
Faithful for Youth (ABY) Partners
Facilitator: Trisha Long,
University of North Carolina - Chapel Hill
Task #1: Introduction*


1a. Think of an object which symbolizes your
work (e.g., a tree, a helping hand, etc.). What is
it, and why does it symbolize what you do?
Share your symbol and something else about
yourself with a partner.
 Time: 5 minutes
1b. We will hear everyone’s symbols as a group.
 Time: 10 minutes
*Introduction exercise from Global Learning Partners
2
Why are we here?

Goal of the BH and ABY programs: prevent new
HIV/AIDS infections among youth and families.





Delay sexual debut and increase abstinence in unmarried youth
and adults.
Increase faithfulness among married youth and adults.
Build capacity of faith-based and community-based
organizations to decrease transmission of HIV/AIDS.
Reduce unhealthy sexual behaviors that increase people’s
vulnerability to HIV.*
Motivational Interviewing helps people change their
behaviors


It is useful when people are ambivalent about changing their
behavior.
It has been shown to be successful in a developing country
setting when applied by non-professional counselors.
*Goals adapted from the BH and ABY proposals
3
Part A: What is Motivational
Interviewing?
After completing Part A, you will have:

Categorized people in various stages of change in
Prochaska’s Model and related their situations to factors
in Barrier Analysis;

Compared an example of MI to an example of health
promotion;

Reviewed evidence of MI’s effectiveness; and

Reflected on the key principles of MI and their
relationship to development work, African culture, and
your faith’s teaching.
What are your questions?
4
Task #2: Identifying Barriers to
Change




2a. The boxes on the next slide show scenarios of people
in different stages of change – they are not in the correct
order. Match the people in the scenarios with their stage
of change.
2b. Based on your knowledge of Barrier Analysis, what
are the determinants of behavior change for each of
these people? Type in the determinants on the right, next
to each person’s scenario.
 Time: 20 minutes
2c. We will hear a sample of your conclusions.
2d. At which stages of change do many development
actions take place?
 Time: 20 minutes
5
Precontemplation
Contemplation
Preparation
Action
Maintenance
Prudence is 18, and single. “It is such a
relief to know that I will not have to worry
about HIV. Since last month, when I made
the decision to be abstinent until marriage,
my heart feels light.”
Behavior Change
Determinants
Benito is 17 years old and single. He has
been having sex for the past three years,
and does not see any reason why he should
stop. He says, “Yeah, I’ve heard all about
getting HIV, but if I am going to get HIV, I
probably already have it by now.”
Samuel is 25 and newly married. “I have
decided I must be faithful to my wife. She
and our future children mean too much to
me to risk their health.”
George is 40 years old, single, and has HIV.
“I have just begun using a condom every
time I have sex so that I will not infect my
partners,” he says. “I hope I will be able to
remember to buy them.”
Jamila is 19 years old, and has been having
sex for money in order to feed her younger
siblings since age 15. “I would like to ask
each man to use a condom so I know I am
at less risk for HIV” she says, “but I do not
think I could do it. Plus, I fear he will
always refuse, and maybe become angry
with me and hurt me.”
6
Precontemplation
Contemplation
Preparation
Action
Maintenance
Mtume is 20 years old, and married for
two years. “If I do not stop sleeping
with other women,” he says, “I am sure
I will bring HIV home to my family. But
what will my friends say? Will they
think I am less of a man if I only sleep
with my wife?”
Behavior Change
Determinants
Hasan is 24 years old. “Since I decided
to be abstinent four months ago, I am
happy with my decision,” he says.
“Sometimes it is hard to wait, but I will
be married soon, and my wife and I will
be safe from HIV.”
Safiya is 14 years old. “I have thought
about this a lot,” she says. “I am ready
to decide to be abstinent. I just need to
know what I should tell my friends.”
Amina is a 35, a wife and mother. “I
haven’t heard much about HIV, but
since I have always been faithful to my
husband,” says Amina, “I could never
get HIV. Besides, when God wants
someone to get HIV, they get it.”
Philip is 32, and married. “I don’t want
my family to experience the stigma of
HIV, even if I am not always faithful to
my wife. I have decided to use a
condom every time I have sex with
another woman.”
7
Task #3: MI and Health Promotion:
How different are they?



3a. Listen to the following examples of health
promotion and motivational interviewing.
 Time: 15 minutes
3b. With a partner, name the differences
between the two methods that you hear.
 Time: 5 minutes
3c. We will hear your ideas.

Time: 20 minutes
8
MI and Health Promotion: Some
Differences

In MI, the person you are speaking to decides what
you will talk about, not you.

There is less direct confrontation or opposition.

Strategies such as “importance scales” are used to
enhance conversation

Ask questions in a positive direction


Good example: “Why is it somewhat important for you to
change? Why is it more than just a little important?”
Health promotion isn’t wrong or bad.

It is not always the right tool for this situation.
9
Task #4: Evidence for the
Effectiveness of MI

4a. Listen to the following
presentations about how
Motivational Interviewing has been
used in an African context and to
prevent HIV.
 Time: 15 minutes
10
Motivational Interviewing in Zambia

From 1999-2001, MI was used in two peri-urban
communities in Kitwe, Zambia, where diarrhea
and clean drinking water had been identified as
major concerns.
The goal of the
intervention was to
encourage adoption of
safe water storage
practices and
purchase of
disinfectant in the
target communities.
11
Health Promotion + MI
Health promotion messages were
delivered using MI by neighborhood
health committee (NHC) volunteers
in weekly visits that were 15-30
minutes long.
An Intervention group received
Motivational Interviewing along with
education.
A Comparison group received
education only.
12
How NHC Volunteers Were Trained

Only the volunteers using MI were trained in MI.
All volunteers received diarrhea prevention and
safe water education.
Local nurses received training
in MI, and then developed and
delivered MI training for the
Neighborhood Health
Committee (NHC) volunteers.
The NHC volunteers received
approximately 10 hours of MI
training.
13
Zambia MI Study, Field Trial #2: Bottles of
Disinfectant Sold/HH (MI vs. Ed. Only), ’98-’99
Field Trial #3: Disinfectant Present in
Stored Water
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Control 2
Follow-up
15
Field Trial #3: Ever Used Disinfectant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Control 2
Follow-up
16
Field Trial #3: Know That Contaminated
Water Causes Diarrhea
80%
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Control 2
Follow-up
17
Field Trial #3: Believe They Can Avoid
Diarrhea
95%
90%
85%
80%
75%
70%
MI
Control 1
Baseline
Control 2
Follow-up
18
Field Trial #3: Know They Can Avoid
Diarrhea by Boiling or Treating Water
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Follow-up
Control 2
19
MI & HIV Prevention

Two trials of an MI-based intervention for HIV risk
reduction in a high-risk population in the U.S.,
conducted through community-based organizations.
Study Population:
Poor, single urban women,
motivationally interviewed in
groups
Average age: 32
Education: Most did not
complete secondary school
Risky behaviors: Drug use,
transactional sex, and multiple
partners, already had a sexuallytransmitted disease
20
MI & HIV Prevention

The immediate effects that were observed:




Increased knowledge of HIV risk
Stronger intentions to adopt safer sex practices
Intentions communicated to sexual partners
Fewer acts of unprotected sex

These effects were mostly sustained at a three-month
follow up.

Effects were partially replicated in a second field trial, by a
4x increase in condom use in the MI Group.

The MI Group women were also more likely to:



Discuss HIV and condom use with partners
Refuse unprotected sex
Get an HIV test
21
Studies Cited



Thevos A, Quick R, and Yanduli V. “Motivational
Interviewing enhances the adoption of water
disinfection practices in Zambia.” Health
Promotion International. 2000; 15(3): 207-214.
Thevos, A.K., Kaona, F. A. D., Siajunza, M.T., &
Quick, R.E. “Adoption of safe water behaviors in
Zambia: Comparing educational and motivational
approaches.” Education for Health. (2000); 13(3):
366 - 376.
Carey, M. and Lewis, B. “Motivational Strategies
Can Enhance HIV Risk Reduction Programs.” AIDS
and Behavior. 1999; 3(4): 269 – 276.
22
Important Limitations


Few studies are in a developing-country
context.
No studies are available in which
abstinence and faithfulness-based HIV
prevention approaches were used.

Most studies focus on risk reduction through
condom use and increased risk awareness.

Studies are often done with high-risk
populations, such as commercial sex workers.
23
Why We Think MI Will Be Effective

People are often ambivalent about sexual
behaviors like abstinence, faithfulness,
and condom use


MI works best with ambivalent people
People expect to be involved in making
decisions about their sexual behavior


MI respects this choice
MI is not coercive
24
Other Situations Where MI has been
Used to Help Individuals Change

These are just a few examples:






Alcohol and drug abuse in adults and teens
Criminal rehabilitation
Adherence to medication regimen or treatment
Weight control
Dietary changes related to health (example:
lowering cholesterol)
General healthcare settings, including
emergency rooms at hospitals
25
Task #4: Evidence for the
Effectiveness of MI




4b. What surprises you about the effectiveness of MI in
these studies?
4c. What is different about the context of your project
from how MI was used in these studies?
4d. What about these examples makes you confident
that MI could be effective in your programs?
4e. How convinced are you of MI’s effectiveness at this
point?
 Time: 15 minutes
26
4e. How convinced are you of MI’s
effectiveness at this point?

A: Very convinced

B: Somewhat convinced

C: Not sure

D: Somewhat skeptical

E: Not convinced
27
Task # 5: Principles of MI

5a. Read the following definition of Motivational
Interviewing.
Motivational Interviewing is a people-centered,
directive method for increasing a person’s inner
motivation to change by exploring and helping
them to resolve ambivalence about a new
behavior.

What strikes you when you read this definition?
Underline that part.

What do you have questions about?

Time: 15 minutes
28
Task #5 continued…

5b. Listen to the following
presentation on motivational
interviewing.

Time: 15 minutes
29
The Guiding Values of MI



Collaborating Together: honors the person’s
experience and perspective. MI does not attempt
to force someone to change.
Bringing Forth Strength for Change:
recognizes that the person already has the
resources and motivation to change, and works to
enhance them. We help people to “drink from
their own wells.”
Free Choice: respects the person’s right to
decide what to do for themselves, and helps them
make an informed decision.
30
Express Understanding

Ambivalence is normal

Use reflective listening


We’ll practice this in Part B
Accepting the person for who they are facilitates
change

This does not mean you must agree with or
endorse their attitude or behavior
“It is okay to feel confused about this issue.”
31
Develop Difference


Change is motivated by perceived
differences between present behavior and
personal values or goals
The person you are talking to discovers
and presents their own arguments for
change
“For what I do is not the good I want to do;
no, the evil I do not want to do--this I
keep on doing.” [Romans 7:19]
32
Roll with Resistance

Avoid arguing for change

Instead, invite a new perspective on the issue
Resistance is a signal to you
to respond differently.
We’ll talk more about
this in Part B.
“Take what you want and leave the rest.”
(Who can argue with that?)
33
Support Self-Efficacy

A person must believe they can
change before change is possible.


Self-efficacy: Barrier Analysis!
People draw on hope and faith as
personal resources for change
Your belief in their ability to change
can be a self-fulfilling prophecy.
34
Task #5 continued…

5c. Divide into three groups and reflect on the
relationships between the values of MI, these principles
and:





Group 1: Development work
Group 2: African culture
Group 3: Your faith
What examples of development interventions, African
cultural beliefs or proverbs, and religious beliefs are
supportive of the values and principles of motivational
interviewing?

Time: 20 minutes

Time: 10 minutes
5d. We will hear all responses.
35
Review of Part A

We related the Stages of Change to Barrier Analysis and
discussed where MI fits in.


We compared MI to Health Promotion.



For what stages of change is MI helpful?
What differences did you notice?
We reviewed the evidence that MI can be effective in our
context.
We discussed the guiding values and principles of MI, and
how they relate to development work, to African culture, and
to religious faith.

Do think MI is compatible with development work, with African
culture, and with your faith?
What are your questions?
36
Homework: Your Stories

Think of two stories from your life where you
were conflicted (ambivalent) about something.

Specifics about the
stories:




You were trying to
change something in your
life (not someone else’s),
either a behavior or a
situation.
There were good reasons
to change, but also good
reasons not to change.
It is okay if you did not
resolve the situation.



The stories can be from
any point in your life (they
need not be recent).
The story should not be so
personal that you would
be unwilling to share it
with the other
participants.
Be able to finish telling the
story in five minutes.
We will tell each other our stories for one
of tomorrow’s exercises.
37
Part B: Basic MI Skills
After completing Part B, you will have:
 Examined an outline of the practice of Motivational
Interviewing;
 Distinguished between open and closed questions;
 Assessed how reflective listening skills can help
develop discrepancy between current behavior and
personal values;
 Experienced, Heard, and Practiced reflective
listening;
 Compared resistance and change talk as indicators of
how the conversation is going; and
 Practiced using motivational interviewing skills in roleplaying situations.
What are your questions?
38
Task #6: The MI Process

6a. Order the steps in the MI
Process on the following diagram.
 Time: 10 minutes
39
Task #6: Order the MI Process
Set the Agenda
Explore Importance/ Values and Build
Confidence
Enhance Motivation to Change (Next: Create Change Plan)
Open Questions
Affirmation
Reflective Listening
Summarizing
Exchange Information
Reduce Resistance
Encourage Change Talk
Establish Rapport
Assess how important they think change is, and
how confident they are that they could change
40
The MI Process: An Overview
Establish Rapport
Assess importance and confidence
Explore Importance/Values and Build
Confidence
Open Questions
Affirmation
Reflective Listening
Summarizing
Reduce Resistance
Exchange Information
Set the Agenda
Encourage Change Talk
Enhance Motivation to Change – Move on to
Part 2, Creating a Change Plan
41
Task #6 continued…

6b. Looking at the MI diagram, what MI techniques
could you use to increase someone’s feeling that it is
important to change their behavior?

6c. What key determinants in Barrier Analysis affect
importance the most?

6d. Thinking about the values and principles of MI, and
OARS, how could you enhance confidence by using MI?

6e. How would low confidence affect importance of
making a change?

6f. How did Afiya, the health promoter in yesterday’s
scenario, assess Imani’s importance and confidence?

Time: 20 minutes
42
Importance & confidence scales

How important is it to you to remain abstinent
before marriage?
1
2
Not important

3
4
5
Very important
How confident are you that you can remain
faithful to your spouse?
1
2
Not confident
3
4
5
Very confident
43
Preview of Part 2: Create a Change
Plan
Summarize arguments for
change/acknowledge reluctance
Ask a key question, like “What
do you think you will do now?”
Provide
information
and advice
Set Goals
Consider change options
Make a Plan
Elicit Commitment to the Plan
Support Commitment to the Plan
Review and Revise Plan, If Needed
44
Task #7: OARS - Open Questions

7a. Which is an open question?
What do you think about abstaining
from sex before marriage?
OR
 Have you and your girlfriend
discussed having sex?

45
Task 7 continued…


7b. With a partner, divide the following
list into open and closed questions.
 Time: 5 minutes
7c. We’ll hear a sample of your
responses.
 Time: 10 minutes
46
Categorize these questions as either:
Open
Closed
What would make it easier for
you to be faithful?
Does your girlfriend ever ask
you if you have other partners?
Who decides whether or not you
will use a condom, you or your
partner?
What consequences of
HIV concern you most?
What are the reasons that you
would want to continue having
sex with your boyfriend?
What are your views on
faithfulness in marriage?
How would being abstinent
before marriage be good for you?
Have you ever been tested for
HIV?
Do you want to stay in this
relationship?
Is this an open or a
closed question?
Have you ever thought about
being abstinent?
Where do you go for
information about HIV?
Do you believe you can
get HIV, even if you are
married?
What do you like about
being abstinent?
47
Correct Answers
Open
Closed







What do you like about being
abstinent?
How would being abstinent
before marriage be good for
you?
What are your views on
faithfulness in marriage?
Where do you go for
information about HIV?
What consequences of HIV
concern you most?
What are the reasons that
you would want to continue
having sex with your
boyfriend?
What would make it easier
for you to be faithful?







Have you ever been tested
for HIV?
Have you ever thought about
being abstinent?
Do you want to stay in this
relationship?
Do you believe you can get
HIV, even if you are married?
Does your girlfriend ever ask
you if you have other
partners?
Who decides whether or not
you will use a condom, you
or your partner?
Is this an open or a closed
question?
48
Task #8: Recognizing OARS


8a. Listen to the following dialogue, which shows
the use of open questions, affirmation, reflective
listening, and summarizing in developing
discrepancy.
8b. Circle or mark the following in your paper
copy of the dialogue:






Two examples of reflective listening
One open question
One example of resistance
One example of affirmation
One example of summarizing
8c. We will hear your responses.
 Time: 30 minutes
49
Affirmation

An affirmation is a compliment!



Praise positive behaviors.
Support the person as they describe difficult
situations.
Examples:


“You seem to be a very giving person. You are
always helping your friends.”
“That situation must have been very painful for
you, but you managed to get through it.”
50
Simple Reflections

Repeat back what the person said.






This is the same as paraphrasing.
Condense your response so that it is shorter than
what they said.
These are statements, not questions.
You can reflect emotions, too.
If you want to move the conversation along, add
something – take a chance!
Examples:


“You had a difficult time confronting your wife about
her infidelity, and now you don’t know how to
approach her.”
“Your mother is really concerned that you will get
pregnant before you finish school.”
51
Amplified Reflections

Strengthen what the person said as you
reflect it.




You can make sure you understood.
If their statement was extreme, you can see if
they really meant it.
If the amplified reflection was too strong or not
correct, the person will tell you.
Examples:


“It wouldn’t matter at all if you got AIDS.”
“It would be impossible for you to be
abstinent.”
52
Double-sided Reflection

A double-sided reflection gives both sides of the
argument.


You’ve heard arguments for and against change, or you’ve
heard two sides of something.
Use “and” or “but” depending on how you want to proceed
in the conversation.



“And” is less confrontational – use “and” if you are hearing
resistance.
“But” emphasizes the last thing you say – “but” may cause
resistance, so use it with caution!
Examples:


“You know your friends will not approve, but you also
know that your parents and your church will approve.”
“Some days it seems as though you will never get out of
this trap, and some days give you hope that things really
could change.”
53
Summarizing

Make a summary statement that encompasses
everything that was said.


Summarizing can be helpful when you want to move
in a new direction.
Examples:


“This has been a really difficult year for you. You
have traveled a great deal, and it has not been easy
to keep your marriage vows when you are away for
so long.”
“You are feeling a lot of pressure to have sex with
this man. He offers you money for nice clothes, to
pay your school fees, and for other things that you
want. Your parents won’t object. You don’t want to
do it, but you feel trapped.”
54
Being Directive

You choose what you reflect from a
discussion.
Being directive helps you move the
conversation toward talking about
change.

How to choose?




Listen carefully.
What are you curious about?
Did you hear a desire to
change?
An idea of how to change?
Follow up on these things!
55
Task #9: Using the OARS

9a. Divide into groups of three.
 Storyteller: tell one of the stories you came up with for
homework
 Pause after every 2-3 statements to give the other
person a chance to listen reflectively.
 Reflective Listener: listen reflectively using OARS as they
tell their story
 Coach: observe the conversation and take notes on the
reflective listener; make notes of both good technique and
areas for improvement.

9b. After the story is complete, the storyteller and the coach
provide feedback to the reflective listener. (5 minutes)

9c. Switch positions and repeat until everyone has had an
opportunity to listen reflectively at least once.

Time: 1 hour
If you have extra time, tell your 2nd story!
56
Task 9 continued…



How did you feel when you were
‘reflectively listened to’?
What good tips did you hear from
your coach and storyteller?
What did you notice about
reflective listening when you were
observing it?
57
Change Talk & Resistance in MI

Change Talk is like a green traffic
signal: it tells you to keep moving
forward!

Resistance is like a red traffic
signal: it tells to stop what you
are doing!
58
Task #10: Recognizing Resistance to
Behavior Change

10a. You will see examples of
different responses to a single
question. Using your voting buttons,
vote on whether the responses are
examples of resistance or not.


 = Yes, it is resistance.
X = No, it is not resistance.

Time: 30 minutes
59
Task # 10: Is it resistance?


Question: “So what do you think
about abstinence before marriage?”
Response: “I don’t think it really
matters if you’re abstinent or not.
That’s a very old-fashioned view.”
 = yes, X = no
60
Task # 10: Is it resistance?


Question: “So what do you think
about abstinence before marriage?”
Response: “Well, sometimes it’s just
not that easy.”
 = yes, X = no
61
Task # 10: Is it resistance?


Question: “So what do you think
about abstinence before marriage?”
Response: “...Nothing, really.”
 = yes, X = no
62
Task # 10: Is it resistance?


Question: “Let’s talk a little more
about abstinence. So what do you
think about-”
Response: “I’d rather talk about my
boyfriend.”
 = yes, X = no
63
Task #10: Is it resistance?

All were examples of resistance.


Sometimes resistance is not an outright
challenge or denial – it can be subtle.
What to do? Roll with resistance.

Christ give us an MI idea:
“But I tell you, Do not resist an evil person.
If someone strikes you on the right
cheek, turn to him the other also.”
[Matthew 5:39]
 In other words, don’t argue back.
64
Task #10 continued


10b. What skills have you already
learned which might help you roll
with resistance?
10c. What resistance to abstinence
and faithfulness might you expect
to hear from participants in the BH
and ABY projects?
65
Shifting Focus
Resistant Statement:
“I suppose now you are going to tell me I
can never have sex again until I am
married.”
 Shifting focus:


Go around the barrier, not over it.
Example: “We’ve only just begun to discuss
this, and you are right - we should not jump to
any conclusions about what you’ll want to do.”
66
Reframing
Resistant Statement:
“I suppose now you are going to tell me I
can never have sex again until I am
married.”
 Reframing:


Acknowledge validity, but interpret differently.
Example: “It’s hard to imagine going without
something like sex for what could be a long
time, you’re right. There are benefits to sex,
definitely, and there are also benefits to
abstinence: you can protect yourself and your
future spouse from HIV.
67
Agree with a Twist
or Emphasize Personal Control
Resistant Statement:
“I suppose now you are going to tell me I
can never have sex again until I am
married.”
 Agree with a twist:



Reflect, and then reframe the discussion
“You’re wondering how difficult it would be for
you to abstain from something that’s really
fun, even if it would protect you from AIDS.”
Emphasizing personal control:

Example: “This is your decision. Even if I
wanted to, I could not make it for you.”
68
“Coming Alongside”
Resistant Statement:
“I suppose now you are going to tell me I can never
have sex again until I am married.”
 Coming alongside:



Take on the anti-change point of view:
Example: “It may be difficult for you to abstain.
Maybe it’s worth the risk of getting HIV to continue
on as you are.”
Use with caution!
Now we’ll hear some more examples of each of
these…
69
Task #11: Practice Rolling with
Resistance

11a. Using the examples of resistance
that we developed in the last exercise,
write two responses using the methods
of rolling with resistance that we just
discussed.

Use a different method of rolling with
resistance for each of your responses.


Time: 10 minutes
11b. We will hear all responses.
 Time: 5 minutes
70
Change Talk in MI


Change Talk is like a green traffic
signal: it tells you to keep moving
forward!
Listen for Change Talk and
encourage it!
71
4 Kinds of Change Talk

Disadvantages of Maintaining the Behavior


Advantages of Change


“It would be wonderful to be married and know for
sure that my wife and I will not have HIV.”
Optimism about Change


“When I am unfaithful, my wife suspects it,
becomes angry, and then we argue.”
“I think I could do it if I tried, and if I convinced
some friends to try it too.”
Intention to Change

“I think I could at least limit my sexual partners so
that I only had one girlfriend at a time.”
72
Task #12: Encouraging Change Talk




12a. Listen to the following conversations. Count
the number of times you hear change talk.
12b. How might you use the importance/confidence
ruler to encourage change talk?

Time: 5 minutes
12c. What other ways might you encourage change
talk? Write down three examples.

Time: 15 minutes
12d. We will hear all examples.

Time: 10 minutes
73
Eliciting Change Talk

Open questions:

What worries you about having sex with your
girlfriend now?

If you did decide to be abstinent, what would
be good about it?


If you resolved to be faithful to your spouse,
what about you makes you think you could be
successful?
So what are you thinking about abstinence at
this point?
74
Eliciting Change Talk

Asking for more details



In what ways do you think your friends would
support your decision to be abstinent?
You mentioned there was a time when you
were tempted to sleep with someone else, but
you didn’t. Tell me more about that time, and
your reasons for avoiding infidelity.
What other difficult decisions have you made in
your life? How did you make them?
75
Eliciting Change Talk

Ask about extreme situations:



What is your biggest concern about AIDS in
the long run?
What consequences of having sex with many
partners do you know of, even if you don’t
think they could happen to you?
If you were completely successful at being
abstinent until marriage, what positive things
would happen?
76
Eliciting Change Talk

Explore the past and the future




Before you had these worries about HIV, what was
your life like?
If you continue on as you are now, what do you
think will happen? Tell me what life will be like for
you in five years.
Think back to when you were first married. How did
you feel about your marriage and your spouse?
How would you like things to be in your future? Tell
me about the best possible future you can imagine.
77
Eliciting Change Talk

Goals and Values





What is most important to you in your marriage?
What do you think people should do about sex
before marriage?
What do you think God wants people to do about
their sexuality within marriage?
What do you value in a spouse? What are the
qualities that you would want for yourself?
What do you think is the right thing to do about
faithfulness in marriage?
78
Remember your OARS!

You can




Ask Open Questions about change
Affirm change talk
Reflect change talk
Summarize reasons for change
79
A Little Motivation



If you are working skillfully, you should be able to stop in the
middle of a conversation and have a sense of what you are
doing, why, and how the person is reacting…
This does not mean that the conversation should be full of
flawless promises to change behavior. Indeed, you both
might be very confused…But you should at least be aware
that this is happening, and have a sense of where to go next
in the conversation.
You do not need to have all the answers…If confused, you can
sometimes be frank with the person to remarkably good
effect.

Paraphrased from “Health Behavior Change”, by Rollnick,
Mason, and Butler, p. 134.
80
Task #13: Practice Motivational
Interviewing!

13a. In pairs, practice your motivational
interviewing skills.



One: Assume a character who is being
motivationally interviewed: you will be given
information about your character, or you may make
up your own.
Two: Practice the motivational interviewing skills we
have been learning.
Take 30 minutes for your first conversation,
debrief for 5 minutes after, then switch roles.

Time: 2 hours, or until end of day
81
Task # 13: Guidance

Characters:



Remember you are ambivalent! Do not be so
resistant that your interviewer has no chance at all!
Do not be too easy on your interviewer, either: you
should not resolve your character’s ambivalence
today. What skills do you want to practice? Give
them the opportunity to practice those, too.
Interviewers:


You will not resolve the problem today. In real life,
you could have many conversations before a person
is ready to consider change. Expect this, listen to
your partner, and respond accordingly.
Go at your partner’s pace. Do not attempt to rush
the conversation just because you are practicing.
82
Review of Part B

We examined an outline of the practice of
Motivational Interviewing.


We distinguished between open and closed
questions.


What is the most difficult part of the process, in
your opinion?
What is an open question?
We assessed how reflective listening skills can
help develop discrepancy between current
behavior and personal values.

What does the acronym OARS stand for?
83
Review: The MI Process
Establish Rapport
Assess importance and confidence
Explore Importance/Values and Build
Confidence
Open Questions
Affirmation
Reflective Listening
Summarizing
Reduce Resistance
Exchange Information
Set the Agenda
Encourage Change Talk
Enhance Motivation to Change – Move on to
Part 2, Creating a Change Plan
84
Review of Part B, cont…

We experienced, heard, and practiced
reflective listening.


We compared resistance and change talk as
indicators of how the conversation is going.


Name one kind of reflection that we talked about.
What are the four kinds of change talk?
We practiced using motivational interviewing
skills in role-playing situations.

How confident do you feel in your ability to
motivationally interview someone? To teach others
to use MI?
85
Review: Guiding Values of MI



Collaborating Together: honors the person’s
experience and perspective. MI does not attempt
to force someone to change.
Bringing Forth Strength for Change:
recognizes that the person already has the
resources and motivation to change, and works to
enhance them. We help people to “drink from
their own wells.”
Free Choice: respects the person’s right to
decide what to do for themselves, and helps them
make an informed decision.
86
Review: Principles of MI

Express Understanding


Develop Difference


Explore differences between personal values,
goals and current behavior
Roll with Resistance


Ambivalence is normal
Avoid arguing with the person
Support Self-Efficacy

A person must believe they can change before
change is possible
87
Part C: Change, Special Cases, and
Problems
After completing Part C, you will have:

Ordered the steps in creating a plan for change;

Listed and examined special groups with whom
your learners are likely to work;

Heard the specific ways in which MI can be adapted
to work with special groups;

Reviewed common problems in using MI and
identified how to avoid them using MI skills.
What are your questions?
88
Task #14: Recognizing Readiness for
Change



14a. Look at this list of behaviors. Circle
those which may indicate that a person is
ready to change.
 Time: 5 minutes
14b. We will hear examples of your
choices.
14c. Which ones surprise you?
 Time: 10 minutes
89
Task # 14: Which Ones Indicate a
Person is Ready to Change?






Asking about change
Trying out a change
behavior
Arguing against
change
Feeling a sense of loss
and resignation
Increased talk about
the problem
Feeling peaceful and
calm





Imagining difficulties
if a change were
made
Blaming others for the
problem
Discussing the
advantages of change
Expressing hope for
the future
Saying the problem
isn’t that bad
90
Task # 14: Which Ones Indicate a
Person is Ready to Change?






Asking about change
Trying out a change
behavior
Arguing against
change
Feeling a sense of loss
and resignation
Increased talk about
the problem
Feeling peaceful and
calm





Imagining difficulties
if a change were
made
Blaming others for the
problem
Discussing the
advantages of change
Expressing hope for
the future
Saying the problem
isn’t that bad
91
Task #15: Creating a Plan for Change


15a. Order the steps in creating a plan
for change.
 Time: 15 minutes
15b. We will hear your ideas.
 Time: 15 minutes
92
Task #15: How would your order these
steps in creating a plan for change?
Consider change options
Summarize arguments for
change/acknowledge reluctance
Set Goals
Make a plan
Elicit Commitment
to the Plan
Ask a key question, like “What
do you think you will do now?”
93
Task #15: Creating a plan for change
Summarize arguments for
change/acknowledge reluctance
Ask a key question, like “What
do you think you will do now?”
Provide
information
and advice
Set Goals
Consider change options
Make a plan
Elicit Commitment to the Plan
Support Commitment to the Plan
Review and Revise Plan, If Needed
94
Summarizing Arguments for Change

Your summary should include:

The person’s own perceptions of the behavior, reflected
in their change talk (disadvantages of status quo)

Acknowledgement of what is attractive about the
behavior

Review of any objective evidence that is relevant to the
importance of change

Restatement of any change talk about intention to
change, and confidence in his or her ability to change

Your own assessment of the person’s situation,
especially when it is similar to their own.
95
Task #15: Creating a Plan for Change


15c. Write two examples of key
questions.
15d. We will hear all questions.
96
Ask a Key Question

More key question examples:

Where does this leave you?

What is your next step? What are your
options?

How do you want things to be for you in the
future?

Of the things we have talked about, what
concerns you most? What do you want to do?

It sounds like things cannot stay the way they
are now. What do you think you might do?
97
Set Goals for Change

Goals are the choice of the person who must fulfill
them:




Don’t try to set goals for the person
Suggest additional goals or milestones, after asking for
permission to do so
Prioritize multiple goals together – use your OARS to
help the person decide what they need to do
immediately, and what they can address later
People may not set goals which are realistic for
themselves


Ask them to rate their confidence in their ability to
achieve the goal
Ask them to consider the consequences of an action
98
Consider Options & Make a Plan

Create a “menu” of options for change




Ask for their ideas on how they could change
Discuss ways in which other people have
changed
Do not impose your own views, or others’
views about how to change on the person
Make a plan for change




Help them verbalize the plan
Write down their plan, if appropriate
Suggest a ‘trial run’ of the plan
Summarize the whole plan
99
Elicit Commitment to the Plan

Another key question: “Is this what
you want to do?”


You hope they will say “Yes.”
If they seem reluctant, do not push
them into saying yes.


Ask them to think and pray about it
until your next meeting.
Emphasize personal choice again.
100
Giving Advice and Information

Before you give unsolicited advice or information:

Ask yourself:




Have I asked the person what he or she thinks
about this subject?
Is the information I will give important to the
person’s safety or likely to enhance their motivation
to change?
Ask the person’s permission
If they ask you for more information or for your
opinion, share it with them in a thoughtful,
sensitive manner.
101
Task #15: Creating a Plan for Change

15e. Listen to the following roleplay demonstrating all the steps in
Part 2 of MI.

Time: 10 minutes
102
Task # 16: Working with special groups

16a. Look at the following list of special
groups with whom you and your
motivational interviewing trainees are
likely to work.


These came from the survey you answered
prior to this training.
16b. In groups of three, list other people
you or your trainees will work with that
you do not see here.
 Time: 15 minutes
103
Task # 16: Who will you work with?

Youth

Mothers

Family and friends

Who else?
104
Tips for working with youth

Not much research published with MI and youth in
general

Even less research done with MI and youth who have
already initiated risky behavior


These youth have often had negative experiences with
adults which may cause them to be more resistant to
change
Rapport is therefore even more important


If you are an authority figure, show them you are
different from other authority figures they have
encountered: acknowledge their doubts, and then show
them with MI that you are not here to give the same old
message
Spend the time necessary to develop an alliance before
asking permission to give advice or feedback
105
Tips for working with groups

Groups amplify behavior: people may take strong
positions or not speak because they are among
peers


Just because you won’t try to ‘fix it’ doesn’t mean
others won’t:


Set ground rules: help them feel safe
Be careful to reframe inappropriate comments,
emphasizing personal control
Use demands for answers as opportunities for
group reflection

Solutions emerge from the group, not the facilitator
106
Group construction…some tips

10-20 people per homogenous group seems ideal

With more people, there is a lot to do - consider two
group leaders:




Discuss how you will work together
You might divide tasks: e.g., rolling with resistance and
expressing empathy
May facilitate breaking up into smaller groups
If possible, don’t overload the group with people who
are not considering change


Try an exercise to see who is thinking about change and
who isn’t
Use your own judgment when forming groups: would it be
advantageous to include some people who have
successfully changed?
107
Tips for working with couples

MI may be used with couples together when both
partners will support change neither will hinder it


In some situations it may be better to pursue MI
individually


Example: a discussion of faithfulness will not cause
one partner to accuse the other of being unfaithful
Example: discussion of a spouse’s unfaithfulness in
front of their partner would threaten that person’s
physical safety
Couples can be taught to use motivational
interviewing skills (example: OARS) with each
other to overcome difficulties in communicating
108
Task #16: Special groups continued

16c. Based on your own experience
working with these groups or types
of people on other projects, what
advice do you think might be helpful
for using motivational interviewing
with them?
109
Task #17: Who’s thinking about
change?

17a. Imagine that you are a youth group leader
using MI techniques to discuss abstinence.
In your groups of three, design an activity that would
tell you how many people in a group are considering
abstinence before marriage, and how many are not.


Your activity should take no more than 5 minutes to
complete
Think about how to adapt your activity for our online
environment.


Time: 15 minutes
17b. We will participate in your activities!
 Time: 15 minutes
110
Task #18: Avoiding the traps!

18a. You will see examples of what
not to do in motivational
interviewing!

Time: 5 minutes
111
Early Traps: Labeling


Raina: So you have been prostituting
yourself.
Sophie: He just pays my school fees. It’s
not the same.
Labels like “prostitute” and “promiscuous”
may increase resistance, and decrease
desire to talk about the behavior in
question. There is no reason to use them.
112
Early Traps: Blaming


Emerson: Even if your wife doesn’t seem
interested, is it permissible to sleep with
others?
Jacob: So it’s all my fault. She has
nothing to do with it.
Blaming serves no purpose in motivational
interviewing, and often increases
resistance, no matter who is being
blamed.
113
More Traps: Gloom for Two
Sophie: What can I do? I have to sleep with him –
my family has no money, certainly none for school
fees. This is the only way I can go to school.
Besides, my parents are happy with this
arrangement: they think I am a connection with
someone influential.
Raina: Wow, that’s awful. [really depressed]
At least one of you has to have hope! Be
empathetic, and use your faith to lend hope to the
other person. This does not mean you must be
unrealistically cheerful.
114
Review of Part C

We ordered the steps in creating a plan for change;

List the steps in creating a change plan.

We listed and examined special groups with whom your
learners are likely to work;

We heard the specific ways in which MI can be adapted to
work with special groups;


What are some tips for using MI with the groups we
discussed?
We reviewed common problems in using MI.

What are the three traps we reviewed?
What are your questions?
115
The Final Quiz
You will see these types of questions:

Questions which ask you to identify a component of motivational
interviewing, or to describe it. (multiple choice and short answer)

Questions which present a short MI conversation and ask you: “What
is happening here which should not happen in MI?” (multiple choice)


Questions which ask you to recover from a mistake made by a
motivational interviewer (e.g., arguing with the person they are
interviewing): “How would you respond?” (short answer) –
Remember that there may be more than one correct way to respond.
Questions which ask you to demonstrate how to respond to a person
using motivational interviewing: “How would you respond?” (short
answer) – Remember that there may be more than one correct way to
respond.
116