Motivational Interviewing

Rolling with resistance

--Accept client reluctance to change as natural rather than pathological. —Reluctance and ambivalence are acknowledged to be natural and understandable. —In MI one does not directly oppose resistance but, rather, rolls or flows with it. —Rolling with resistance is psychological judo. —Resistance that a person offers can be turned or reframed slightly to create a new momentum toward change. —Client "resistance" is a signal for the counselor to shift approach. —Resistance is something that occurs only within the context of a relationship. —Dissonance in counseling is not the product of only one person's behavior. —Respect the person. —Your goal is not to argue for change but rather to express an understanding of the person's point of view while emphasizing person choice. —Resistance is change specific.

Resistance may come from counselor behaviors - 6 ways

1) Arguing for change 2) Assuming the expert role 3) Criticizing, shaming, or blaming 4) Labeling 5) Being in a hurry 6) Claiming preeminence

Change talk - 4 categories

1) Disadvantages of the status quo 2) Advantages of change 3) Optimism for change 4) Intention to change

Eliciting change talk - 6 ways

1) Evocative questions 2) Asking for elaboration 3) Querying extremes 4) Looking back 5) Looking forward 6) Exploring values and goals.

Resistance can result in three kinds of talk

1) Resistance talk. Negative comments about treatment or about the relationship with you. 2) Sustain talk Statements about sustaining a behavior and not engaging in change. 3) Lack of communication Silence Telegraphic speech Asking, "Huh?"

Components of a change plan - 5

1) Setting a SMART goal. 2) Delineating steps to reach that goal 3) Reviewing reasons to reach the goal 4) Identifying potential barriers 5) Deciding what to do to overcome barriers.

A simple reflection

A "simple" reflection is when you repeat or paraphrase the person's words without adding any specific meaning or emphasis on the content of what has been said. If your simple reflection is met with silence, try to resist filling the silence immediately.

A double-sided reflection

A double-sided reflection is a reflection in which both sides of client ambivalence are presented usually separated by the word "and." It serves to point out the discrepancy between the person's values or goals for change, and how her behavior(s) may detract from helping her to attain these outcomes. With a double-sided reflection, begin with the negative side of change and end with the positive side of change.

Evoking change planning

A type of question asked after the client seems motivated to make a change which moves the session into the "planning phase." Usually follows a recapitulation summary that brings together much of the client's change talk. —What's the next step? —Where would you like to go from here? —What are your options at this point? —How do you foresee yourself making these changes? —What are your plans for the next week? —What are some other reasons you think now is the time to make these changes? —What else might you do? —Why else do you think you could succeed? Use SMART goals framework.

Change talk

Change talk refers to the client's own arguments for change. It refers to any client comments that reflect movement toward change. Listen for change talk. Elicit and reinforce you client's argument for change. As a person argues for one position (positive or negative), he becomes more committed to it. "As I hear myself talk, I learn what I believe."

Statements predicting change

Client statements that reflect motivation for and commitment to change predict subsequent behavior change. Client statements, positive or negative, can be influenced by counseling style.

Scaling questions

Scaling questions are questions that ask for an answer on a scale, usually from 1 to 10. —Follow up questions to begin to elicit change talk: —Why did you pick ___ and not a lower number? —What would it take to move it to a higher number? —Do not ask why the number isn't higher. This will likely give you "sustain talk" — the opposite of change talk —Scaling questions are a good way to assess motivation. —Motivation is change specific.

Eliciting reasons for the status quo

Tell me more about the things you like about . . .

The righting reflex (offering solutions)

The Righting Reflex refers to the tendency on the part of the counselor to offer solutions or suggestions to the client. To be helpful. To make things right. To correct an unhealthy course of action. The righting reflex is the human tendency to correct things that are perceived as wrong. It is a natural desire of helping professionals. The righting reflex must be avoided if one is to practice skillful MI. The righting reflex often translates into premature problem solving and advise giving, which prevents people from being actively involved in the process, and actually places them in a passive role. This righting reflex stifles autonomy and can engender rebellion by the young person.

Ambivalence with change talk

The ambivalent person will often follow change talk with an undermining statement. Nonetheless, reinforce the change talk in the statement. Address the barrier after you reinforce the change talk

Resolving ambivalence - decisional balance sheet

The decisional balance sheet asks four open questions: 1) What are the advantages of changing? 2) What are the disadvantages of changing? 3) What are the advantages of the status quo? 4) What are the disadvantages of the status quo?

Developing discrepancy

You can promote behavior change by evoking, reflecting, and even magnifying the discrepancy between the person's values and goals and their current status quo behaviors. In developing discrepancy, it is critical that you focus on the young person's behavior and values, not your own values or social norms. This is where motivation for change begins. No discrepancy = no motivation.

Minimizing reflection

Minimizing reflections understate the reasons for change or the problems the person has had because of not changing. Minimizing reflections increase the likelihood of the young person responding with arguments for change. "You've only had a few really minor difficulties as a result of . . . ." —If the person agrees with the minimizing reflection (instead of arguing for change) such as, "you're right, I haven't had any problems from . . . . It may be wise to "come along side" and reflect that now may not be the time to change. He may then argue for change or you may focus on other behavior.

Motivational interviewing definition

Motivational interviewing is a form of guiding to elicit and strengthen a person's motivation for change in accordance with his/her own values and goals.

Change

One person cannot make another person change.

Respect the person

Respect the person as being the expert of him or herself and as possessing the mechanisms and internal resources to make a change — the personal values, motivations, abilities, and skills — with or without your advice.

Belief in change

People who believe that they are likely to change do so. People whose counselors believe that they are likely to change do so.

Discord

Discord is a misalignment in the relationship you have with your client. Not being on the same page. Talking at cross purposes. Experienced as: Being in an argument with your client Working harder than your client. "Discord" replaces the concept of "resistance."

Supporting self efficacy

Embrace client autonomy - even when clients choose not to change.

Evoking

Evoking is eliciting the person's own perspective, the person's own motivation, and the person's own arguments for change

Directive reflection

Reflection is not a passive process. It can be quite directive. The counselor decides what to reflect and what to ignore, what to emphasize and deemphasize, what words to use in capturing meaning. Reflections can be used to reinforce certain aspects of what a person has said or to alter its meaning slightly. Change talk is preferentially reflected, so that people hear their own statements.

Change planning

Focus on the frequency and intensity of change talk. You should be hearing commitment language of increasing strength before moving on to a specific plan for change. Sustain talk should be diminishing (though it may not disappear). Backtracking to sustain talk happens often in the face of commitment. In the face of continued sustain talk, you need to back up the conversation, roll with resistance, and further explore ambivalence. Some behaviors are not intrinsically pleasurable (i.e., coming home at curfew) and may always elicit feelings of ambivalence. Ongoing ambivalence is a natural part of the journey of change. Use a summary to transition to the next phase of developing a plan for change. The summary: —Synthesizes the ambivalence discussions —Highlights the strength of the commitment to change —Ends with a key question If you are interested, I can share some things other teens have tried. What ideas do you have about specific steps to get started? We are about finished with our time today, and this is when you might consider setting a goal for yourself. I understand you are not yet ready to make a change. If it's OK with you, we can set a goal around something you are ready to do. What do you think about that?

Affirmation

I appreciate that you took a big step in coming in here today. You are clearly a resourceful person to cope with such difficulties for so long. I must say, if I were in your position, I might have a hard time dealing with that amount of stress. It seems like you're a really spirited and strong willed person in a way. I've enjoyed talking with you today.

Cons and pros of the NEW behavior

If it's OK with you, I would like to understand more about your view of the situation. Tell me the not so good things about [the new behavior]. What are the good things that happen when you . . . . If the person cannot come up with any pros (for the new behavior): "So right now you are not sure there are any reasons to change." "If you would like to hear them, I have some pros other people have mentioned about . . . ." "Some people have found that they . . . ." Teens do not respond well to discussing the cons of a behavior that others want them to avoid. Instead, focus on the cons and pros of adopting a NEW behavior. First, elicit reasons for the status quo behavior. "Tell me more about the things you like about . . . ." This helps establish rapport, roll with resistance, and further understand the barriers to behavior change. Then you can more safely ask for the pros of the new behavior without eliciting resistance. When the focus is on a new behavior, first ask about the cons, then reflect and summarize ("Tell me the not so good thing about [the new behavior]"). Then ask for the pros of the new behavior. ("What are the good things that happen when you . . . ?") Ask permission. "If it's OK with you, I would like to understand more about your view of the situation. I am wondering what are the bad things about [the healthy behavior]?" "On the other side, what might be some reasons for [the healthy behavior]?" If the person cannot come up with any pros, reflect "So right now you are not sure there are any reasons to change." "If you would like to hear them, I have some pros other people have mentioned about . . . ." "Some people have found that they . . . ."

Resistance - Shifting focus

If other strategies do not help to reduce resistance or ongoing sustain talk, you may shift the conversation focus away from sustaining the status quo behavior. Steer the conversation around the stumbling blocks to other areas of therapeutic discussion. You may also include a simple reassuring statement to the the person. You do not have to focus on something he or she is not ready to discuss.

Asking permission

In all encounters, ask for permission before engaging in a task. If it is OK with you, I would like to find out more about your _____? Would you be willing for us to write down the behaviors we just agreed to focus on in our sessions?

The Amplified Reflection

In an amplified reflection, you emphasize and intensify the sustain talk in the reflection. There is no reason at all for you to . . . . If your tone is straight forward and honest, then these reflections will often elicit, "Yeah, but" statements followed by reasons to change. Amplified reflections can be tricky. You must convey an attitude of empathy and not sarcasm. Too extreme of an overstatement or a reflection in the form of a question may elicit further resistance. If the person responds to an amplified reflection with agreement ("you're right, I have not had any problems from . . . .), it may be wise to "come alongside" and reflect the now may not be the time to change. The young person may then argue for change or you both may decide to focus on other behaviors.

Discrepancy

You can promote behavior change by evoking, reflecting, and even magnifying the discrepancy between the person's values and goals and their current status quo behaviors.

Ambivalence

—Ambivalence is wanting and not wanting something at the same time. —Ambivalence is having conflicting desires, needs, reasons, and other motivations for changing behavior. —Ambivalence produces anxiety. You want to be able to hold your client in the anxiety producing ambivalent state long enough to explore both sides thoroughly until your client begins to tip the balance toward healthy behavior change. Do not argue for change. The client may resist your argument and argue for the status quo. People believe what they hear themselves saying. Hearing his own arguments, the client may become more entrenched in continuing unhealthy behavior. —Ambivalence is a normal aspect of human nature. —Passing through ambivalence is a natural phase in the process of change. —"Lack of motivation" can be viewed as unresolved ambivalence. —Ambivalence is not an obstacle to change. Rather it is ambivalence that makes change possible. —When reflecting ambivalence, consider using "and" rather than "but" to link discrepant components. Other linking phrases such as "on the one hand . . . and on the other" and "at the same time," can also be useful.

Eliciting change talk - Exploring values and goals

—Ask about how the target behavior fits with the client's values and goals. This will often reveal discrepancies between your client's current behavior and his values and goals. —When behavior comes in conflict with a deeply held value, it is usually the behavior that changes. —A general principle of MI is to create and amplify, from the client's perspective, a discrepancy between present behavior and his broader goals and values. —What are some of your goals for the future? How does _____ fit with these goals? —What do you value most in life? What are you doing now that is inconsistent with your values? How can you change your behavior to be more consistent with your values? —(It is important to express empathy around short-term needs (managing stress), which may be in conflict with long-term values and goals.) —It must be hard knowing that eating sugary foods satisfies your hunger, but yet can mess up your diabetes in the long run." —It must be hard knowing that _____ calms your situation in the short term but can mess up your life in the long run.

Hope and self-efficacy

—Hope and faith are important elements of change. —Self-efficacy is the belief in one's ability to be competent in specific situations. It is a person's belief in his or her ability to carry out and succeed with a specific task. —The counselor's own expectations about a person's likelihood of change can have a powerful effect on outcome. —Change occurs when he/she deems the behavior important and when he/she feels able to make the change. --When you take a stance of hope and optimism for successful behavior change and express an honest belief in the perons's ability, the person is likely to feel more competent and therefore behavior change is more likely to occur. —Self-efficacy is change specific.

Eliciting change talk - Advantages of change

—How would you like for things to be different? —What do you think needs to change in your life? —What would be the good things about _____? —What would you like your life to be like five years from now? —If you could make this change immediately, by magic, how might things be better for you? —What would be the advantages of making this change? —The fact that you are here indicates that at least part of you thinks it's time to do something. What are the main reasons you see for making a change? —So you might consider making a change if it would reduce the hassle you experience with your [wife, parents, etc.]. What would it take to make that happen?

Eliciting change talk - Disadvantages of the status quo

—What worries you about your current situation? —What makes you think that you need to do something about your _____? —What difficulties or hassles have you had in relation to your _____? —What is there about your _____ that you or other people might see as reasons for concern? —In what way does your _____ concern you? —How has this stopped you from doing what you want to do in life? —What do you think will happen if you don't change anything? —I am interested in what you think. What concerns you about your _____? —Everyone is telling you what needs to change. What do you want? What part of your life feels less than perfect for you right now?

Responding to shocking statements

—When a teen comes up with a shocking statement, respond with a question expressed with curiosity, not judgement. —"How did you think I would react to that statement?" —By asking a question you elicit, rather than interpret, the meaning behind the statement.

Reflections

—Reflections are made to the client that mirror, give back, repeat, rephrase, paraphrase, or otherwise make manifest what the client says with words or body language. It is a guess or hypothesis about what the client is thinking and feeling. —You should deliver reflections confidently as statements with your voice inflection going down rather than up at the end. How you inflect can make or break the impact of your reflection. They stand alone and don't need to be followed by a question such as "Is that right?" —You can use stems like: —It sounds like . . . . —That makes me think . . . . —If I understand you correctly . . . . —What I am hearing . . . . —So . . . . —What you're saying is . . . . However, in most situations, it is generally preferable to drop the stem. —If you reflect adequately, even if you are wrong, it will not slow the conversation. The client will just correct you and continue with the conversation. —It is best to slightly understate what the speaker has said - especially the emotional content. If you slightly understate the expressed intensity of emotion, the person is more likely to continue exploring and telling you about it. If you overstate the intensity of an expressed emotion, the person will tend to deny and minimize it, backing off from the original statement. —Reflection is particularly important after open-ended questions. Once you have asked an open question, respond to the client's answers with reflective listening. Stay out f the question-answer trap, just asking a series of questions. Respond reflectively to the client's statements. Follow up a question with reflective listening rather than another question. Skillful counselors offer two or three reflections on average per question asked and about half of all their responses are reflections.

Resistance

—Resistance is speech that signals movement away from a particular kind of change. —When there is resistance from a person, monitor your own behavior and step back. —It is difficult for a person to fight against a practitioner who maintains a neutral stance and offers an appreciation of the dilemma of change. —Wrestling requires two people, and if you stop, the person cannot continue to wrestle. —Psychological reactance occurs in response to a perceived threat. You diminish reactance by becoming less threatening in your communication. —Avoid persuasion. The more you try to persuade, the more the young person resists. --Counselor behavior can elicit and intensify client resistance and thus decrease the probability of behavior change. --Counselor "advocacy" that argues for a particular cause tends to elicit and reinforce resistance behavior. —The theory of psychological reactance predicts an increase in the rate and attractiveness of a "problem" behavior if a person perceives that his personal freedom is being infringed or challenged. —Resistance is often the result of overestimating the young person's readiness to change. A good guide never gets too far in front. —The simplest way to respond to resistance talk is with a simple reflection.

Early questions

—Some counselors like to ask people first what they have liked about their current "problem" and what the not-so-good side includes. —Tell me about your use of _____. What do you like about it? Then later . . . . What are your concerns about _____? —I understand that you are here to talk about your _____. So help me see the big picture. What do you like about _____, and what's the not-so-good side? —Tell me what you've noticed about your _____ over the years. What changes have you seen and how have these affected you? —What is it that other people are concerned about? —What has happened that other people think you need to be here? —What do other people hassle you about? —I can't change what happened that made others think you need to be here, but I can help you explore what's going on and how you decide you want to handle it

Sustain talk

—Sustain talk is client speech that reflects desire for the status quo. —Sustain talk includes statements about: Intentions not to change. Advantages of the status quo Disadvantages of change Pessimism about change —Increases in change talk are associated with behavior change in adults. However, with teens, reductions in sustain talk appear to be even more related to behavior change than are increases in change talk statements.

Eliciting change talk - asking for elaboration

—Tell me more about . . . . —Tell me more about how you overcame difficulties in the past. —What other successes have you had with changing habits? —You said you were able to . . . . How did you do it? —In what ways? How much? When? —Asking for a specific example. —Asking for a description of the last time this occurred. —What else? —Why would you want to . . . ? —How will you do it? —How do you know you could do it if you tried . . .? —What are the three best reasons you would ...?

Eliciting change talk - Looking forward

—To help me understand more about you I am wondering if you are willing to share how you see things in your future? What do you imagine life will be like, say, five years from now? How does _____ fit with this goal? —How would you like things to turn out for you 10 years from now? —Suppose you don't make any changes, but just continue as you have been. What do you think your life would be like 10 years from now? —If you do decide to make a change, what do you hope might be different in the future?

Eliciting change talk - Looking back

—What are the differences between the John of 10 years ago and the John of today? —Do you remember a time when things were going well for you? What has changed? —What were things like before you started _____? What were you like back then? —Tell me about a time in the past when things were different. —What were you like before you went to war? —How have you overcome difficulties in the past? —What goals did you have for yourself when you were younger? —You said you were able to . . . . How were you able to do that?

Eliciting change talk - Intention to change

—What are you thinking about your _____ at this point? —What do you think you might do? —How important is this to you? —How much do you want to do this? —What would you be willing to try? —I can see that you are feeling stuck at the moment. What's going to have to change? —Of the options I have mentioned, which one sounds like it fits you best? —Never mind the "how" for right now — what do you want to have happen? —So what do you intend to do?

Eliciting change talk - Optimism about change

—What encourages you that you can change if you want to? —How confident are you that you can make this change? —What makes you think that if you did decide to change, that you could do it? —What do you think would work for you if you decided to change? —If you decided to make a change, how would you do it? —What personal strengths do you have that will help you succeed? —Who could offer you helpful support in making this change? —In what else in your life have you made a significant change like this? How did you do it?

Eliciting change talk - Querying the extremes

—You can ask about the best and worst things that could happen if the client could change the behavior or, alternatively, didn't change the behavior. —Imagining extremes involves asking future oriented questions pertaining to how life would be if the problematic behavior continues or discontinues. —The looking forward strategy is especially powerful because it instill hopefulness about how life may one day be different. —However, this strategy can backfire, increasing resistance if you are not prepared to roll with any and all responses he or she may offer. —What is the best thing that could happen if you started . . .? —What is the best thing that might happen if you decided to stop ____? —What might be the best results you could imagine if you make a change? —If you were completely successful in making the changes you want, how would things be different? —What is the worst thing that might happen if you continue _____? —What is the worst situation you could imagine happening if you continue to . . .? —What concerns you most about your _____ in the long run? —Suppose you continue on as you have been, without changing. What do you imagine are the worst things that might happen?

Eliciting change talk - personal strengths

—You can encourage stories regarding past change successes related either directly to the target behavior or to other difficult changes. —You could inquire about successfully accomplished goals from the past, personal strengths or social supports available to help with overcoming challenges. —For the young person who does not easily identify personal strengths, you can explore what other people (friends, family) say about their strengths or good qualities.