Motivational Interviewing

Promoting Equipoise (balance of interests or focus)

"I can see that you've really been struggling with this dilemma and feeling stuck. That's very common in a situation like this. Thinking about either alternative is uncomfortable, and so it's tempting to try not to think about it; but that's uncomfortable, too, because nothing is resolved or changed. What I suggest we do is to explore both sides of this dilemma rather thoroughly. I want you to know that I intend to remain completely neutral about what you should do and not advise you one way or the other, but just help you take a good close look at what your choices are. You may find this process uncomfortable—people often do—but I think that's what you need to do to get unstuck. I will work with you and support you until you decide what you want to do, and then help you move in the direction you've chosen. Do you have any questions about this process I have described? Shall we proceed?"

What summarizing does to ambivalence

"This friendship really evokes some strong feelings for you. On the one hand you're drawn to him. He's interesting. You've never quite known anyone like him, and he's had experiences that are way outside anything that has ever happened to you. You also feel a kind of bond with him. He seems to understand you in uncanny ways. At the same time his perspective sometimes borders on the bizarre, and his insights can creep you out occasionally. He seems needy and lonely, and while that makes your friendship important to him, you also can feel drained by him. You're drawn toward him and drawn away from him simultaneously. Both things are true, and it leaves you feeling confused about this relationship." Each of the strands in this summary may have been reflected and explored individually as the person spoke them, but in this summary something else happens. The strands are woven together into a fabric, a single piece that contains all their colors. Offered such a summary, a person can really "get" how he or she is stuck, see the whole picture of the forest in a way that wasn't clear from examining one tree at a time.

How to summarize (3)

"Well, it sounds like your life is pretty stressful. When you wake up in the morning you often feel bad. You have a stressful commute in traffic in the morning, and you put in a lot of time at work. By the time you get home, you're exhausted. You're a single mom now, and there's a constant battle with your ex about getting time with your kids. You really miss them when they're not with you, but you also feel kind of helpless to do anything about it. Mostly what you do in the evening is watch TV, and alcohol helps you to relax. Have I got it right?" captures the emotion but leaves the client feeling down "Let me tell you what I hear so far. Because of some lab tests, Dr. Clark is concerned that you are drinking too much, and asked you to talk to me. You're wondering what the lab test means, and you don't understand how you could still have been legally drunk that morning. Some mornings you do feel pretty bad, though. On the other hand, alcohol helps you to relax, and you don't think you really drink all that much. You don't drink in the morning, and you certainly don't think you're an alcoholic. You weren't too happy to come here, and you don't want to be lectured about drinking. Is that about right?" captures the ambivalence "So here's what you've told me so far. Dr. Clark noticed a blood test elevated that often is a warning about drinking too much, and she was concerned enough to call you personally. That scared you a little. You were also surprised that there was still enough alcohol in your bloodstream for you to be arrested for drunk driving if you had been stopped, even though you had not had anything to drink in the morning. If that happened, you could lose your job. When you wake up in the morning you often feel pretty bad—headache, tired, nervous. That seems to happen more when the kids aren't with you, and you drink more at night. What else have you noticed?" quintissential- pulls together the change talk

The Labeling Trap

"You have diabetes," "You're an alcoholic," "You're in denial," etc. Because such labels often carry a stigma in the public mind, it is not surprising that people with reasonable self-esteem resist them. Even in the field of alcohol problems, where emphasis on labeling has been high (at least in the United States), there is little evidence for any benefit from pressuring people to accept a label like "alcoholic."

Ways to promote change talk from sustain talk (7)

-Amplified Reflection -Double Sided Reflection -Emphasizing Autonomy -Reframing -Agreeing with a Twist -Coming Alongside -Looking back

In MI, where is the confrontation?

-Not with someone else: with oneself. -Within a supportive, nonjudgmental context, people look in the mirror to reflect on their own behaviors, attitudes, and values. - There is no need to "get in their face" to make it happen. -An MI approach honors autonomy, trusting in their own natural wisdom and desire to grow in a positive direction.

Reflective listening involves responding to the speaker with a statement that is not a roadblock, but rather is _______ about what the person means. This moves the conversation forward.

-One's best guess INTERVIEWER: How have you been feeling lately, since your surgery? CLIENT: It was quite an ordeal, I can tell you. I'm lucky to be here. INTERVIEWER: You could easily have died. CLIENT: They said there was 90% blockage, and at my age that kind of surgery is major, but I made it through. INTERVIEWER: And you're glad. CLIENT: Yes, I have plenty to live for. INTERVIEWER: I know your family is important to you.

The Premature focus trap

-people become engaged in a power struggle about proper topic for discussion -starting with the person's own concerns rather than the counselors ensures that this does not happen

Reasons why people might avoid discrepancies between their values and reality?

1) The "Goldilocks principle" applies here: the discrepancy should not be too large or too small, but "just right." If the discrepancy is too small, it may not appear important enough to prompt action. If it is too large, the needed change may seem beyond reach. 2)Relatedly, a person may perceive a substantial discrepancy but feel unable to do anything about it. This lack of self-efficacy may be because the discrepancy seems too large, or just because the needed skill is beyond one's ken: "I have no idea how to do it." 3) Furthermore, a discrepancy can evoke such unpleasant experiences that the person simply avoids thinking about it as a matter of self-defense. It is just too painful to look in the mirror.

Three possible directions from which to derive focus in therapy

1) The Client: "I need to quit smoking." "Help me get back custody of my children." "I've been feeling really depressed." 2) The Setting: A smoking cessation clinic A suicide prevention hotline "My wife says I need to quit smoking." "The judge told me to I have to be here or go to jail." 3) and The Clinician: Quite commonly, people will seek services with one goal in mind, and in the course of consultation the clinician working with them perceives that another kind of change is needed. The client did not come to the clinician with this in mind (at least not in presenting concerns). So a challenge for the clinician is how to raise the subject and explore the client's willingness to entertain this additional goal or direction. A mother brings a child to the pediatrician for treatment of asthma and yet another upper respiratory infection. The physician wants to talk about the parents' smoking as a contributing factor. An unemployed man seeks help in finding a job. The counselor perceives the client's appearance and hygiene to be significant obstacles to hiring.

3 Positives of Affirming

1) Trust 2) Affirming also reduce defensiveness. When confronted with information that threatens their self-image, people are naturally inclined to self-affirm their autonomy and strengths, and doing so seems to diminish the threat to personal integrity. Relatedly, affirmation can increase openness to potentially threatening information, particularly when the affirmation precedes defensive responding. 3) Affirming the possibilities in others may also directly facilitate change, just as demeaning stereotypes can impede it. Sometimes it is also possible to reframe discrepancy from shame to opportunity, from pessimism to possibility.

4 elements of acceptance

1) accurate empathy (accurately understanding the person's own experience), 2) autonomy (honoring the person's choice and self-determination), 3) absolute worth as a human being, 4) and affirmation.

How to evoke confidence

1) Ruler question/ strength finder "Why are you at a ____ and not a 0" 2) Review past successes 3) Brainstorming- coming up with as many ideas as possible for how a change might be accomplished 4) Hypothetical Thinking "What I'd like you to do is imagine that it's 5 years from now and you have succeeded in making this change that you want. Write a letter to yourself from the future. Can you imagine that? Offer some words of encouragement from this future, wiser self and write about how you managed to accomplish this change." "Peter, I'd like to try something a little different if you're willing. In a minute I will ask you to move to that chair over there and to take the role of my consultant. When you do, we will talk about your situation together as if you were my consultant, to help me think about what to do. When we do this, talk about yourself not as 'I' or 'me,' but as a third person: 'he.' Do you understand?" "I'm feeling a little stuck at the moment in working with Peter, and I'd like your advice. I really want to help him, and I can't quite see what would be a good next step. What do you think is going on with Peter, and what might I try?"

5 great questions for invoking people to want to make a change for themselves:

1. "Why would you want to make this change?" 2. "How might you go about it in order to succeed?" 3. "What are the three best reasons for you to do it?" 4. "How important is it for you to make this change, and why?" Your friend listens patiently, and then gives you back a short summary of what you have said: why you want to change, why it's important, what the best reasons are, and how you could do it in order to succeed. Then your friend asks one more question, and again simply listens as you reply: 5. "So what do you think you'll do?"

What can you do to invoke discrepancy?

1. Ask client what they already know 2. Elicit-Provide-Elicit 3. Provide feedback from questionnaires 4. Exploring Other's concerns "Why do you suppose your wife is concerned? What do you think she is seeing?" 5. Exploring goals and values "How does smoking fit in with each of your most important values? Do you think it helps you achieve them, conflicts with them, or maybe is irrelevant? Have a look at these values that you have identified and tell me what you think."

DARNs

Desire, Ability, Reasons, Need

Salesperson technique to invoking change

If you as a helper are arguing for change and your client is arguing against it, you've got it exactly backward. Ideally, the client should be voicing the reasons for change. Any successful salesperson knows this.

JOHANN WOLFGANG VON GOETHE quote

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.

Looking back

Sometimes it is useful, in eliciting change talk, to have the client remember times before the problem emerged and to compare these times with the present situation: "Do you remember a time when things were going well for you? What has changed?" "What were things like before you started using drugs? What were you like back then?" "Tell me about how you two met, and what attracted you to each other back then."

When giving advice, what is the most important thing? 2 strategies for this...

Maintaining the patient's autonomy! 1) Language emphasizes that they are the best judge of their personal decisions: "It's really up to you, but I can describe some options." "This advice may not be right for you." 2) Provide a variety of options rather than suggesting them one at a time. Making one suggestion (as in the parenting example above) seems to invite sustain talk. A menu of possibilities prompts a different mind-set: Which of these options might be best? Rather than coming up with objections to a single suggestion, the client's task is to consider a range of possibilities and choose among them.

The Blaming Trap

Whose fault is the problem? Who's to blame? If this issue is not dealt with properly, time and energy can be wasted on needless defensiveness. One obvious approach here is to render blame irrelevant within the counseling context. Usually this can be dealt with by reflecting and reframing the person's concerns. If this problem arises, for example, the person may be told: "It sounds like you're worried about who's to blame here. I should explain that counseling is not about deciding who is at fault. That's what judges do, but not good counselors. Counseling has a no-fault policy. I'm not interested in looking for who's to blame, but rather what's troubling you, and what you might be able to do about it.

Absolute Worth

Absolute Worth:There is a fascinating paradox here. We concur with Rogers that when people experience themselves as unacceptable they are immobilized. Their ability to change is diminished or blocked. When, on the other hand, people experience being accepted as they are, they are freed to change. -maybe it's something like- "sure, there are things about yourself that you might not like, but you as an individual are absolutely worthy and accepted, despite your flaws."

Accurate Empathy

Accurate Empathy: empathy is an ability to understand another's frame of reference and the conviction that it is worthwhile to do so. Rogers and his students described well the therapeutic skill of accurate empathy. It is "to sense the client's inner world of private personal meanings as if it were your own, but without ever losing the 'as if' quality"

What can you do to help people become more accepting of themselves?

Affirmation itself can have a strong impact in helping people be open to discrepancy and change. Perhaps even more powerful than affirmations coming from you are self-affirmations that you can evoke from the client.

How to know if a client is becoming defensive?

Blaming—"It's not my fault." Minimizing—"It's not that bad." Justifying—"What I'm doing makes sense." Squaring Off Interrupting Disengagement

What is the biggest reason that people do not change?

By far and away the most common place to get stuck on the road to change is ambivalence. Most people who smoke, drink too much, or exercise too little are well aware of the downside of their behavior. Most people who have had a heart attack know full well that they ought to 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 positive side, most people can also describe the merits of saving money, being physically active, recycling, eating lots of fruits and vegetables, and being kind to others. Yet other motives conflict with doing the right thing, even when you know what it is. Ambivalence is simultaneously wanting and not wanting something, or wanting both of two incompatible things. It has been human nature since the dawn of time.

CATs

Commitment, Activation, Taking Steps

Ratio of questions to effective listening

Counselors skillful in MI offer two to three reflections on average per question asked, and about half of all their responses (not counting the short "uh-huh" type of utterance) are reflections. In coding ordinary counseling sessions, in contrast, we find that questions often outnumber reflections by a ratio of 10 to 1, and reflections constitute a relatively small proportion of all responses.

How to use DARNs to begin to evoke change

D- Desire questions most often contain verbs such as want, wish, and like. There are many different ways to ask about desire for change. "What do you wish for in your marriage?" A- Ability questions ask about what a person can do, is able to do, or more gently (in the hypothetical) what they could do (which does not commit them to doing it). "If you did really decide you want to lose weight, how could you do it?" R- Reason questions ask for specific reasons why. They explore if ... then reasons for considering or making a change. "What's the downside of how things are now?" N- Need language expresses an urgency for change without necessarily giving particular reasons. Need questions may well evoke reasons (which is just fine if it happens). Again, there are many ways to ask. "How serious or urgent does this feel to you?"

How do people feel when they are asked these questions?

EE! Oh you!! 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)

The rhythm of advice offering in MI?

Elicit-Provide-Elicit CLIENT: Exactly; it calms me down then knocks me over again. I don't like it. INTERVIEWER: I wonder if I might tell you some things that I've noticed with other people who were struggling with alcohol. [Asking permission] CLIENT: All right. INTERVIEWER: [Provide:] When people drink to settle their nerves, the kind of shakiness that you're describing gradually gets worse over time. It feels like alcohol helps in the short run, but it actually causes the shaking and becomes a problem instead of a solution. It's a real trap because it feels like a terrible panic, and then alcohol calms you down for a little while. How does that sound to you? [Elicit]

Emphasizing Autonomy

Emphasizing that people do have a choice seems to make it more possible for them to choose change. As discussed in Chapter 11 in relation to coercive language, telling people (inaccurately) that they "must" or "have to" or "can't" is a recipe for reactance. "CLIENT: I really don't want to exercise. INTERVIEWER: And it's certainly your choice. No one can make you do it."

Questions to elicit CAT talk

Evoking activation talk "Are you willing to give that a try?" Committment "Is that what you intend to do?" Preparing/ Actions "What would be a first step?" Setting a date/ Taking steps "When do you think you'll go?"

Reframing

Familiar to cognitive therapists is the idea of reframing: suggesting a different meaning or perspective for what the person is describing. "CLIENT: My wife is always nagging me about this. INTERVIEWER: She must really care about you." "CLIENT: I've been through so much lately. I don't know if I want to take this on, too. INTERVIEWER: You're quite a survivor." Reframing is not a matter of arguing about the correct perception—just inviting the person to consider a different angle of view. Uncertainty becomes a challenge, almost a dare. Nagging bespeaks love. The normal becomes the exceptional. Adversity reflects strength. "CLIENT: I don't know if I can do it. INTERVIEWER: It would be quite a challenge for you—hard work!"

What is motivational interviewing for?

Having an aspiration for the client that they might not necessarily share. Trying to move them closer to box A.

How to be a guide in the conversation/ multiple agendas

In essence, agenda mapping is a metaconversation. It is a short period of time when you and your client step outside of the conversation to consider the way ahead and what to talk about. Essentially, it is a form of "talk about talk." Agenda mapping can involve identifying one step to focus on within an ongoing process of change. Done well, it can provide relief to clients who feel ensnared by their problems, giving them a chance to leave some things to one side for a while as they focus on others. 1. step back, go into the hypothetical First, it is a good idea to make clear what you're doing. "Would you mind if we consider some topics that we could discuss?" 2. consider topics 3. switch between zooming in and zooming out a. The big map: A list of topics or goals that you have considered together. You can include topics that you will or might discuss, as well as any that you won't be addressing together. b. The focal map: Your starting point for the conversational journey. This may be one topic or a set of high-priority topics to be addressed. c. A reminder that you can return to this mapping task again as needed later in your consultation. This provides a reference point you can use later to step aside again for agenda mapping. d. Asking for the client's response. Is this agreeable? Are there additional concerns that need to be addressed soon? Is it all right to proceed? 4. use visual aids- map it all out

Where does MI live in the helping conversation continuum?

In the middle is a guiding style. Imagine going to another country and hiring a guide to help you. - It is not the guide's job to order you when to arrive, where to go, and what to see or do. - Neither does a good guide simply follow you around wherever you happen to wander. BUT A skillful guide is a good listener and also offers expertise where needed. Helping a child to learn a new task involves guiding—not doing too much or too little to help.

What must happen before a discrepancy can be addressed?

Ironically, it is when people experience acceptance of themselves as they are that change becomes possible. Causing people to feel bad and unacceptable usually entrenches the status quo. When you provide acceptance you make it possible for people to consider a larger discrepancy, to entertain it without shying away.

Continuum of helping conversations

It is possible to think about helping conversations as lying along a continuum. At one end is a directing style, in which the helper is providing information, instruction, and advice. A director is someone who tells people what to do and how to proceed. The implicit communication in directing is "I know what you should do, and here's how to do it." At the opposite end of this continuum is a following style. Good listeners take an interest in what the other person has to say, seek to understand, and respectfully refrain (at least temporarily) from inserting their own material.

Autonomy

Telling someone that "You can't," and more generally trying to constrain someone's choices typically evokes psychological reactance (Dillard & Shen, 2005; Karno & Longabaugh, 2005a, 2005b), the desire to reassert one's freedom. On the other hand, directly acknowledging a person's freedom of choice typically diminishes defensiveness and can facilitate change. This involves letting go of the idea and burden that you have to (or can) make people change. It is, in essence, relinquishing a power that you never had in the first place.

When there seems to be little desire for change at present:

Querying extremes ask to imagine the extreme consequences: "What concerns you the most about your high blood pressure in the long run?" "Suppose you continue on as you have been, without changing. What do you imagine are the worst things that could happen?" "How much do you know about some of the things that can happen if you drink during pregnancy, even if you don't imagine this happening to you?" At the other extreme, it can be useful to imagine the best consequences that might follow from pursuing a change: "What do you think could be the best results if you did make this change?" "If you were completely successful in making the changes you want, how would things be different?" "Imagine for a minute that you did succeed in___________. What might be some good things that could come of out that?"

What is a linking summary?

Reflecting on what a person has said and linking it to a prior conversation "You're really pleased that you managed to exercise every day this week, and you even started feeling a kind of high from running. I wonder if that's like the way you felt that day when you hiked up to the mountain lake all by yourself."

Agreeing with a Twist

The IMPACT of a REFRAME may be INCREASED by prefacing it with a reflection that acknowledges and essentially sides with what the person is saying. It's hard to argue with someone who is agreeing with you. The twist, the suggested reframe, is mentioned without particular emphasis, almost in passing, and again without any hint of sarcasm. Agreeing with a twist contains the benefits of reflection and of inviting the person to consider things in a different light.

Roger's on the heart of discrepancy

The cards are shuffled and then the person sorts them into five to nine piles ranging from "very unlike me" to "very much like me." In Rogers's approach the cards were then reshuffled, and the person sorted them again, this time according to how he or she would like to be—the "ideal self." The degree of discrepancy between "real" and "ideal" perceptions of self was a measure of interest to Rogers. In his theory of personality, psychological health is reflected in a close correspondence between real and ideal self-perceptions, and a decrease in this discrepancy would be an expected positive outcome of client-centered counseling.

Motivational interviewing and values

Understanding a person's values also can play a key role in MI. An individual's broader life goals represent an important potential source of motivation for change. It is a common human experience for day-to-day behavior to fall short of or even contradict longer-term life values. Such value-behavior discrepancies become apparent precisely through reflection on life values, and perceiving such discrepancy can exert a powerful effect on behavior (Rokeach, 1973).

The trouble with asking assessment questions at the beginning

The disadvantages of using tests at the outset of a series of therapeutic contacts are the same as the disadvantages of taking a complete case history. If the psychologist begins his work with a complete battery of tests, this fact carries with it the implication that he will provide the solutions to the client's problems.... Such "solutions" are not genuine and do not deeply help the individual. During such an exchange, the client has virtually no chance to talk him- or herself into change. It also sets the stage for the next obstacle to a collaborative relationship, the expert trap.

And yet... Carl Rogers on gullibility

The kind of caring that the client-centered therapist desires to achieve is a gullible caring, in which clients are accepted as they say they are, not with a lurking suspicion in the therapist's mind that they may, in fact, be otherwise. This attitude is not stupidity on the therapist's part; it is the kind of attitude that is most likely to lead to trust, to further self-exploration, and to the correction of false statements as trust deepens. The curious paradox is that when I accept myself just as I am, then I can change.

DARNs and CATs

The uphill side represents preparatory change talk (like DARN), and the downhill side is mobilizing change talk (like CATs). One thing to ask yourself during a consultation is where you are on the hill.

Amplified Reflection

This essentially turns up the volume a bit on the client's statement. It accurately reflects what the person has said, adding to its intensity or certitude. The intent behind such overstatement is to evoke the other side of ambivalence: change talk. "CLIENT: I think things are just fine in our marriage the way they are. INTERVIEWER: There's really no room for improvement." An amplified reflection not only acknowledges what the person is saying, but also takes it up a notch in search of the other side of ambivalence.

Importance of values in MI

Understanding a person's values also can play a key role in MI. An individual's broader life goals represent an important potential source of motivation for change. It is a common human experience for day-to-day behavior to fall short of or even contradict longer-term life values. Such value-behavior discrepancies become apparent precisely through reflection on life values, and perceiving such discrepancy can exert a powerful effect on behavior

Coming Alongside

When all else fails to yield change talk, try coming alongside. This is essentially agreement without a twist. Joining with the person's sustain talk, even with a bit of amplification, will sometimes trigger some change talk. "CLIENT: I've tried this "exposure" stuff myself, and it doesn't work for me. I just get too anxious. I start to confront my fear, and then I feel like I'm going to die and I back off. It's not for me. INTERVIEWER: It really may be too difficult for you. It's not everyone's cup of tea, even though it's effective. Exposure means experiencing and getting through the fear, and it may not be worth the discomfort. Perhaps it's better to stay as you are."

When do you know when a person is in the action phase?

When you hear action language "I bought some running shoes so I can exercise." "This week I didn't snack in the evening." "I went to a support group meeting."

Double Sided Reflection

acknowledge both sides of the ambivalence and use AND rather than BUT to give them the perception of both having seriousness. Also state the sustain talk before the change talk so that it will have more saliency "You think it's going to be a real challenge to change the way you cook and eat, and you also know how important it is to keep your blood sugar level regulated."

commitment language signals the likelihood of _____. It sounds like:

action Perhaps the clearest is "I will." Emphatic versions include "I promise," "I swear," and "I guarantee." "I give you my word" It's not: "I want to." "I could." "I have good reasons to." or "I need to."

in ambivalence, there are two types of talk, what are they?

change talk- the person's desire to change sustain talk- the person's desire to stick with the status quo

Affitmations

to seek and acknowledge the person's strengths and efforts