Motivational Interviewing

Directing style

a natural communication style that involves telling, leading, providing advice, information, or instruction

A director is someone who tells people what to do and how to proceed

This implicitly communicates “I know what you should do, and here’s how to do it

The recipient of the direction has a complementary role

obeying, adhering, and complying

Common examples of directing

• A physician explaining how to take a medication properly

• A probation officer explaining the contingencies and consequences imposed in court

Following style

a natural communication style that involves listening to and following along with the other’s experience without inserting one’s own material

Good listeners

• Take interest in what the other person has to say

• Seek to understand

• Respectfully refrain (at least temporarily) from inserting their own material

This implicitly communicates

I trust your own wisdom, will stay with you, and will let you work this out in your own way.

The recipient of the following style has a complementary role

taking the lead, going ahead, and exploring

There are times in most practices when following is appropriate – simply listen as a human companion

e.g., with a dying patient for whom everything necessary has been done or a client who enters a session with strong emotion

Guiding style

a natural communication style for helping others find their way, combining some elements of both directing and following

Imagine going to another country and hiring a guide to help you

• It’s not the guides job to order you when to arrive, where to go, and what to see or do

• The guide also doesn’t follow you around wherever you happen to wander

• A skillful guide is a good listener and offers expertise where needed

MI lives in this middle ground between directing and following

Incorporates aspects of each

Many selfless motives can draw people into helping professions

– A desire to give back

– To prevent and alleviate suffering

– To manifest the love of God

– To make a positive difference in the lives of others and in the world

Ironically, these motives can lead to the overuse of the directing style

This is an ineffective or even counterproductive way when the task is helping people to change

The Righting Reflex

the natural desire of helpers to set things right, to prevent harm and promote client welfare. Relies particularly on directing

– Helpers want to help

– Seeing people head down the wrong path stimulates a natural desire to get out in front and say, “Stop! Go back! Don’t you see? There is a better way over there!”

• This is done with the best of intentions. With one’s heart in the right place

Consider…

– Most people who need to make change are ambivalent about doing so

– They see both reasons to change and reasons not to

– They want to change, and they don’t want to… all at the same time

Ambivalence is an ordinary part of the change process

If you’re ambivalent, you’re one step closer to changing

There are also some who need to make a change (at least in the opinion of others), but themselves see little or no reason to do so

– Perhaps they like things just the way they are

– Maybe they’ve tried to change in the past and given up

For these people, developing ambivalence about change

would be a step forward

Ambivalence

simultaneously wanting and not wanting something, or wanting both of two incompatible things

Ambivalence is the most common place to get stuck on the road to change

– Most who smoke, drink too much, or exercise too little are aware of the downside of their behavior

– Most people who have had a heart attack know full well that they should quit smoking, exercise regularly, and eat more healthily

– Most people with diabetes can recite the dreadful consequences that can ensue from poorly controlled blood glucose

On the bright side…

Most people can describe the merits of saving money, being physically active, recycling, etc.

• Other motives conflict with doing the right thing even when you know what it is

In ambivalence, it’s normal to hear two kinds of talk mixed together

change talk and sustain talk

Change talk

any client speech that favors movement toward a particular change goal

Sustain talk

any client speech that favors status quo rather than movement toward a change goal

• Status quo – the current state of affairs without change

In ambivalence, change and sustain talk occur naturally… often in the same sentence…

– “I need to do something about my weight [change talk] but I’ve tried about everything and it never lasts [sustain talk].”

– “I mean, I know I need to lose weight for my health [change talk] but I just love to eat [sustain talk].”

– “Yes, but…” is the cadence of ambivalence

Even though its uncomfortable, people get stuck in ambivalence

– Take a step in one direction and the other starts looking better

– The closer you get to one alternative

• The more its disadvantages become apparent

• The more nostalgia for the other beckons

A common pattern:

think about a reason to change, think about a reason not to change, then stop thinking

The path out of ambivalence is to choose a direction and follow it

Keep moving in the chosen direction

Consider what happens when an ambivalent individual meets a helper with the righting reflex…

– The ambivalent person already knows the arguments for and against change

– The helper’s natural reflex is to take up the “good” side of the argument

• Explaining why change is important and advising how to do it

Example of talking with an alcohol-dependent person

Helper: “You have a serious drinking problem and you need to quit.”

– The fantasized reply is: “Oh, I see. I just didn’t realize how serious it is. Ok, that’s what I’m going to do!”

– The likely reply is: “No I don’t.”

– The person has already heard the “good” arguments

• Not only from others, but also from a voice within

Most people tend to believe themselves and trust their own opinions

more than that of others

Causing someone to verbalize one side of an issue tends to

move the person’s balance of opinion in that direction

People learn about their own attitudes and beliefs in the same way that others learn them

– By hearing themselves talk

So…

– If you are a helper arguing for change and your client is arguing against it, you’ve got it exactly backwards

– Ideally, the client should be voicing the reasons for change

The righting reflex involves the belief that

you must convince or persuade the person to do the right thing

The primary assumptions of addiction treatments before MI

– In order to make the person change you had to

• Ask the right questions

• Find the proper arguments

• Give the critical information

• Provoke the decisive emotions or pursue the correct logic

– This calls forth a massive righting reflex from the helper

• Confront the person with reality, provide the solution, and when you meet resistance, turn up the volume

– It isn’t effective…

Most often, the “helped” person feels some, if not all, of the following

– Angry (agitated, annoyed, irritated, not heard, not understood)

– Defensive (discounting, judged, justifying, oppositional, unwilling to change)

– Uncomfortable (ashamed, overwhelmed, eager to leave)

– Powerless (passive, one-down, discouraged, disengaged)

Sometimes, the person being “helped” concludes that he or she actually doesn’t want to change!

If someone asks why you want to make a change, how you would accomplish that change, good reasons to change, how important it is to make the change and why. then summarizes what you said and asks what you think you’ll do

Most often, the “helped” person feels some, if not all, of the following

– Engaged (interested, cooperative, liking the counselor, ready to keep talking)

– Empowered (able to change, hopeful, optimistic)

– Open (accepted, comfortable, safe, respected)

– Understood (connected, heard, listened to)

In both cases, the subject of the conversation is the same

- a possible change characterized by ambivalence

The outcomes tend to be quite different

Which would you rather spend your time working with?

– Angry, defensive, uncomfortable, and passive people who don’t like you; or

– People who feel engaged, empowered, open, and understood and rather like their time with you

They are the same people

– The difference is in the dynamics of the conversation

Motivational Interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change

it is first and foremost

– a conversation about change

– Always a collaborative conversation, never a monologue

• Can be brief or prolonged

• May occur in many different contexts (e.g., with individuals or groups)

– Primary purpose is to strengthen motivation for change – the person’s own motivation

Steps of Change in MI

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

6. Relapse

There are four key elements of the spirit of MI

– Partnership

– Acceptance

– Compassion

– Evocation

MI is not something done by an expert to a passive recipient, a teacher to a pupil, a master to a disciple

MI is an active collaboration between experts

– People are the undisputed experts on themselves

• No one has been with them longer, or knows them better than they do themselves

– In MI, the helper is a companion who typically does less than half of the talking

MI is like dancing rather than wrestling

One moves with, rather than against the person

Why is partnership important?

– When the goal is for another person to change, the counselor can’t do it alone

– The client has vital expertise that is complementary to your own

A pitfall here is to avoid the expert trap

– The expert trap is communicating that, based on your professional expertise, you have the answer to the person’s dilemma

– Avoiding this trap

• Includes letting go of the assumption that you are supposed to have and provide all the right answers

Your purpose is to

– Understand the life before you

– See the world through this person’s eyes

• Rather than superimposing your own vision

Acceptance is Rogerian and involves at least four aspects

– Absolute worth

• Prizing the inherent value and potential of every human being

• Also known as non-possesive caring or unconditional positive regard

– Accurate empathy

• The skill of perceiving and reflecting back another person’s meaning

– Autonomy support

• The interviewer accepts and confirms the client’s irrevocable right to self-determination and choice

– Affirmation

• The interviewer accentuates the positive, seeking to acknowledge a person’s strengths and efforts

To be compassionate is to

– Actively promote the other’s welfare

– Give priority to the other’s needs

Compassion is a deliberate commitment to pursue the welfare and best interests of the other

Much of what happens in professional counseling about change is based on a deficit model

Deficit model – the person is lacking something that needs to be installed

• The implicit message is

– “I have what you need, and I’m going to give it to you”

» This could be knowledge, insight, diagnosis, wisdom, reality, rationality, or coping skill

Evaluation is so often focused on detecting deficits to be corrected by professional expertise

• Once you know the missing ingredient, then you will know what to install

This approach is good for automobile repair

• It doesn’t work well when personal change is the focus of the conversation

The spirit of MI starts from a very different strengths-focused premise

– That people already have within them much of what is needed

– Your task is to evoke it… to call it forth

– The implicit message is

• “You have what you need, and together we will find it.”

Once people resolve their ambivalence about change, they often go ahead and do it on their own

Without additional professional assistance or permission

Principle 1 of Person-Centered Care (Rogerian)

1. Our services exist to benefit the people we serve (and not vice versa)

– The needs of clients (participants, patients, consumers, customers, etc.) have priority

Principle 2 of Person-Centered Care (Rogerian)

2. Change is fundamentally self-change

– Services (treatment, therapy, interventions, counseling, etc.) facilitate natural processes of change

Principle 3 of Person-Centered Care (Rogerian)

3. People are the experts on themselves

– No one knows more about them than they do

Principle 4 of Person-Centered Care (Rogerian)

4. We don’t have to make change happen

– The truth is that we can’t do it alone

Principle 5 of Person-Centered Care (Rogerian)

5. We don’t’ have to come up with all the good ideas

– Chances are that we don’t have the best one

Principle 6 of Person-Centered Care (Rogerian)

6. People have their own strengths, motivations, and resources that are vital to activate in order for change to occur

Principle 7 of Person-Centered Care (Rogerian)

7. Therefore, change requires a partnership, a collaboration of expertise

Principle 8 of Person-Centered Care (Rogerian)

8. It is important to understand that person’s own perspective on the situation, what is needed, and how to accomplish it

Principle 9 of Person-Centered Care (Rogerian)

9. Change is not a power struggle whereby if change occurs we “win”

– A conversation about change should feel like dancing, not wrestling

Principle 10 of Person-Centered Care (Rogerian)

10. Motivation for change is not installed, but is evoked

– It’s already there and just needs to be called forth

Principle 11 of Person-Centered Care (Rogerian)

11. We cannot revoke people’s choice about their own behavior

– People make their own decisions about what they will and will not do

– It’s not a change goal until the person adopts it