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