MOTIVATIONAL INTERVIEWING GETTING STARTED WITH MOTIVATIONAL COUNSELING

Patrick McKiernan PhD, CADC

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Overall Seminar Goal2

• Provide a quick start to motivational counseling: – Focus on practical clinical aspects– TRY to limit theory and concepts– Increase ability to implement MI– Increase practice skills – Increase supervision/evaluation

skills• Exposure to research that is changing

motivational interviewing practice

MI intervention overview (big picture)

MI targeted behavior: Create and sustain engagement in an adherence change plan. Follow Doctor’s recommendations

Meditational: Different than actual treatment adherence.

Key point: MI is behavior specific

MI is highly strategic Advanced counselors are more strategic… Strategic: More efficient (briefer) and

effective Client state is continually assessed

Navigational map Counselor utterance is a strategic response

Few client states Relatively few MI strategies Memorize

Influences and References5

Client Centered Therapy (Carl Rogers): Non Directional

Motivational Interviewing (Miller & Rollnick): Directional Approach

Self Determination Theory (Deci and Ryan): Psychological Needs & Quality of Motivation

Transtheoretical Stages of Change (Prochaska and DiClemente): Process of change

Behavioral Economics (newly applied to change): Time value and temporal effects on decision making.

Rooted in Natural Change6

• Self-actualization tendency (Rogers)• Adaptive creatures Systems perspective

– Manipulate environment to meet their needs and desires

– Opening up a closed system• Self Determination Theory: Human

thriving– Subtle nature of motivation… behavior

doesn’t follow behavioral principles…– Better motivation is more value driven

RESEARCH ON MI: Meta Analysis

Important distinction from Hettama (p. 108)

MI does NOT communicate “I have what you need.”

BUT RATHER“You have what you need, and together we

will find it.”

Research on MI:Works as Standalone or Front End

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Phase I vs. Phase II Before and after commitment to change.

MI works as a standalone intervention

As a front end for some other intervention to increase treatment adherence

Phase IMotivational Counseling

Phase II:Open ended menu of options

Phase IMotivational Counseling

Phase II:Some prescribed treatmentemphasized (e.g., Lincoln Trail)

Meta Analysis: Summary The evidence base for MI is extremely

strong in addiction and growing in health. Evidence base is vast “72 target clinical

trials spanning a range of target problems (Hettema, 2005)”

Current research is focused on finding “why” and “how” it works.

Research on learning: Best learned through practice.

Meta Analysis Works better than alternative approaches with

with people from ethnic minority groups. angry and resistant, or less ready for change

clients. MI as preparation for any other treatment program

High effect sizes are observed Improves tx adherence and retention The effect endures across time

When MI is used as a standalone rapid impact of MI gradual de-crease of effect size across time Implications: Booster sessions Use as a stepped care program (followup built in) Used as fallback (followup built in)

What is motivation?

How do we change it?

Miller & Rollnick on, What is motivation?

• Motivation: Mediates MI tx adherence• Measurement: Recognition or action

– Ambivalence is difficult to measure• Complex construct: Not feeling, thought,

behavior;… rather, a drive / energy / fuel

• Dynamic / volatile across time and environment

• M&R: Ready (committed), willing (important), and able (self-efficacy / confidence)

SIMPLE NAVIGATIONAL MAP

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WORKING ALLIANCE(red)

Importance of Change

Commitment to Change

Change Plan

?? Temporal Effects ??

Change Confidence

Major influences and trendsWhat is MI?

Nature of Change Discussion15

Think of some non-trivial behavioral change that you or someone you know attempted? Smoking, diet / weight, exercise, etc.

What important values or goals were the impetus for change?

Was it self change or aided change? What helped? What didn’t help? Did education help?

Describe pattern of change across a long period of time. Lapse?

Application to yourself

1. Think of one change you would like to make in your life.

2. How ready do you feel to make this change?

3. Use a rating ruler to rate your readiness to change:

NOT READY TO CHANGEUNSURE READY TO CHANGE TAKING ACTION

1 2 3 4 5 6 7 8 9 10

Phase I: Continual assessment determines strategy (RICC)

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1.Relationship: How strong is my

relationship with this person?

2.Importance: Is change important to

him/her? Is he or she ambivalent?

3.Confidence: How confident are you that you can change if you

tried? Will self efficacy support change plan?

4.Commitment: What do you want to do?

Note: All counselor strategies should be ideally directed at

advancing one of the four RICC components.

Therapeutic Relationship (TR or working alliance) Dilemma

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• Strong TR is related to greater change.• How will we know the level of TR?

– Will they tell us? Can we ask?– If they do, can you rely on what they

say?– Can you judge?

• Can only best be judged through counselor behaviors.

• Problem: Requires preventive efforts and hyper vigilance.

Therapeutic Relationship (TR)19

Rogers: Create an environment for self-actualization TR

Synonym: Working alliance RULE: A TR is a requirement for

facilitating change. No TR / No change.

What are risks to TR?

Developing & Maintaining TR20

Spirit of Motivational Interviewing Psychological needs (self-determination

theory) Autonomy / internal locus of control Challenge / competency / self efficacy Relatedness

All of the MI principles aid in increasing TR Express empathy --Support self

efficacy Understand resistance --Develop

discrepancy

TR: Risk and Protective FactorsSupportive /

Protective Accurate

understanding (or empathy) Client talks>50% Support autonomy Convey competency Sponsor relatedness Affirm and accept (unconditional positive regard) Understand

resistance Discover

goals/values Ask permission for

risk factors

Risk factors*• Observe / confront• Give advice / fix it• Educate / fix it• Share opinion• Take on authority

role• Debate / argue /

defend• Being rushed• Fail to listen• INACCURATE • REFLECTIONS!!!*Avoid whenever

possible. Ask permission when

necessary.

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Risk created by brevity22

Poor TR Blocks chance to help Avoid TR risk whenever possible Brevity: Need for balance Know when you

are taking risk Calculate risk Mend fences Monitor client relationship Risk is minimized by asking

permission and tone in which you give advise, educate, or observe

3 Strategies to improve importance

1. Assess importance and elicit most important reasons for change with rulers

2. Use decisional balance exercises to fully assess, clarify, and organize ambivalence

3. Life plan discovery: Explore past successes and future plans to achieve important goals and values (desired or ideal)

• Raises discrepancy

Strategies to improve importance 1) Use of the Importance Ruler

Efficiently assesses importance Also discovers most important reasons for

change. How: “On a scale of 1 to 10, how important

is making a change?” If client is high (8 or above) in importance,

summarize and move to assessment of CONFIDENCE

If client response is 7 or below, elicit most important reasons for change with a ruler

Why would you say a [stated value] compared to [stated value minus 3 or 4].

Strategies to improve importance2) Decisional Balance Exercises

Decisional balance Weighted list of pros/cons. Aids the client (and the counselor) in clarifying level of

ambivalence vs. importance. What are the good things and not so good

thinks about recovery? List them. Pros/Benefits/Good things (the pros and change and cons of

status quo) Cons/Costs/Not so good things (cons of change and pros of

status quo) KEY Response: Reflect the underlying value.

Every pro or con has an important value/goal attached to it…. OR THEY WOULDN’T MENTION IT.

Making that connections increases brings clarity.

Transtheoretical Stages of ChangeProchaska & DiClemente

Trans. Stages (process) of Change.Where does clinical purpose shift?

Stage of Change Precontemplative

Contemplative Preparation /

Determination Action Maintenance Relapse

Client Process Unaware Pre-crystallization Unwilling Discrepancy (conflict

with important goals/values) Discouraged Support self efficacy Ambivalent Discrepancy tips scale Commit & prepare

Collaborate on treatment plan.

Carryout Tx plan / learn Relapse prevention / refine

Overcome shame / regain confidence

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MI 2nd Edition: 2 Phases of Change1. Uncommitted to change: Resolve ambivalence

in two forms… Important? Awareness of value incongruence. Confidence? Self-efficacy—will it work? can I

do it? Phase 2 shift marked by intent /

commitment

2. Committed: Collaborate on change plan Collaborate / menu of choices for action

plan… Continue to assess for importance /

confidence Termination

MI Sandwhich

MI Assessment “sandwich” concept: MI strategies during opening 20

mins Agency intake assessment MI strategies during closing 20 mins

MI emphasis on “spirit”30

• Open ended question: Begin with how or what.

• Spirit (SDT research based version): – Autonomy (emphasize client choice) – Competency (they have what they need),– Relatedness (peer relationship, no

authority).

• Reflections– Good: Simple (paraphrase)– Complex: Reflect emotion or change

meaning

DISCOVERY: Achieving 2 Ends31

• Interview for most important goals and values (ideal life) Achieves 2 ends– People crave to be understood– Initiates the process of raising importance.

• Focus on constructing a vision of the clients desired (or ideal) life.– Value clarification

• Spirit: Use TR protective strategies and avoid TR risks.

Discovery: Common Values/Goals32

Health Money / security Relationship with some romantic partner Wellbeing of children and family Psychological needs (SDT): Autonomy /

competency / relatedness Will favor experiences that promote these Relatedness: Social support peer vs.

authority.

TR Risk: Nuance33

Some people are harder than others Greater or lesser need for controlling

interaction Depressed people are oftentimes preferring

advice and more assertive TR Trap: Clients are accustomed to being

treated in an authoritative way. Will they complain if you are typical of other

professionals? Normal??? How will they notice if you are “different than

other counselors.” Will they tell you?

Accurate Empathy & Reflections34

Empathy is conveyed with reflections Statement of understanding

Simple reflection: Parroting or paraphrasing Complex reflection: Changing or adding

meaning or emotion Reflections are better than questions…

Conveys understanding Does not cause pause to consider question. Keeps conversation on Clients track, not our

own. Accelerates the pace of the interview

Motivational Interviewing Clinical Interview: Putting Responsibility for Change on the Patient.

Simple Reflection Shifting Focus Reframing Rolling with

Resistance Siding with the

Negative Self-Efficacy

Avoiding Arguments Open-ended

Questions Listen Reflectively Expressing Empathy Develop Discrepancy Affirm

REFLECTINGACCURATE EMPATHY

Ongoing method to communicate understanding and stimulate deeper instropsection

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KEY: Management of Self 37

TIMING… Never suggest a planning idea until Phase II change planning.

***Manage YOUR RIGHTING REFLEX Hard to observe someone in pain

or suffering without reacting Makes us want to fix Fix it statements are not good

Our righting reactions must be managed!!!

Impatience and burn out are also sources of reactionary problems.

Myth? Resistance or Denial

Despite the common belief, researchers have suggested that there is no denial, only resistance (caused by paradox).

Addicted people are aware of problems related to drinking.

People will become resistant in response to confrontation or emphasizing the need for change (paradoxical response). It’s not denial it’s resistance caused by paradox

Strategies to improve importance 1) Use of the Importance Ruler

Efficiently assesses importance Also discovers most important reasons for

change. How: “On a scale of 1 to 10, how important

is making a change?” If client is high (8 or above) in importance,

summarize and move to assessment of CONFIDENCE

If client response is 7 or below, elicit most important reasons for change with a ruler

Why would you say a [stated value] compared to [stated value minus 3 or 4].

Strategies to improve importance2) Decisional Balance Exercises

Decisional balance Weighted list of pros/cons. Aids the client (and the counselor) in clarifying level of

ambivalence vs. importance. What are the good things and not so good

thinks about recovery? List them. Pros/Benefits/Good things (the pros and change and cons of

status quo) Cons/Costs/Not so good things (cons of change and pros of

status quo) KEY Response: Reflect the underlying value.

Every pro or con has an important value/goal attached to it…. OR THEY WOULDN’T MENTION IT.

Making that connections increases brings clarity.

Strategies to improve importance3) Life planning discovery

Clarifies, aids client in healthy life planning Protracted dialogue on achieving the desired

(or ideal) life Desired life: Goals and values discovered

previously Explore… how can you achieve the desired life

while continuing to use… look forward, look back. Explore… how would it be different if you were to

decide to change your drinking.