Motivational Interviewing: Learning The Basics
University of Massachusetts Medical SchoolCenter for Tobacco Treatment Research and TrainingMotivational Interviewing:Learning the BasicsTTS – Motivational InterviewingThis module must be conducted by an instructor experienced in teachingabout motivational interviewing. This slide presentation may be used ifdesired with exercises selected by the instructor.The following concepts must be covered: Spirit of MI Principles – RULE Micro Skills; OARS Resources for intensive trainingPlease maintain the following slides: 6, 7 and 561
Course ObjectivesSpirit and principles of motivationalinterviewingBasic skills of motivational interviewingHow to utilize reflective listening skillsCategories of change talkNegotiating an action planTTS – Motivational Interviewing2
What is your style?Health Education ModelClient‐Centered TherapyCognitive Behavioral Therapy (CBT)Solution‐Focused Brief TherapyDialectical Behavior Therapy (DBT)12‐Step ModelMotivational InterviewingOther TTS – Motivational InterviewingMotivational Interviewing is only one style of counseling. It can be combinedwith many other styles and is often the pre-cursor to these styles.3
What is MotivationalInterviewing?Working through (with) Ambivalence toFacilitate Change4TTS – Motivational Interviewing4
Stages of ChangeTTS – Motivational Interviewing5
MI and Tobacco TreatmentPatient‐centered method used by physiciansdemonstrated increased quit rates (Ockene et.al, 1991)Reviews and meta‐analyses found a trend forincreased quit rates with MI vs usual care/briefadvice (Lai et al, 2010; Lindson‐Hawley, Thompson & Begh, 2015)May have limited effectiveness with some groups(Okuyemi et al, 2007; Catley et al, 2016)MI to build motivation followed by cognitive &behavioral strategies may be most effectivemodelTTS – Motivational InterviewingPlease maintain this slide to highlight some references to the evidence supporting the useof MI in tobacco treatment.The reports by Okuyemi and Catley unexpectedly found that MI was not more effective intheir studies with participants who were primarily low-income African Americans.Encourage the use of MI especially with tobacco users who have not yet committed tochange. Those ready and willing to change should be provided with behavioral strategyoptions that will be covered in the Cognitive and Behavioral Treatment Strategies module.REFERENCES: Heckman, CJ. Egleston, BL., & Hofmann, MT. (2010) Efficacy of motivationalinterviewing for smoking cessation: A systematic review and meta-analysis. TobaccoControl. 19(5):410-416. Lai, DT., Cahill, K., Qin, Y., & Tang, JL. (2010). Motivational interviewing for smokingcessation. Cochrane Database Systematic Review(1). Ockene JK, Kristeller J, Goldberg R, et al (1991). Increasing the efficacy of physiciandelivered smoking interventions: A randomized clinical trial. Journal of General InternalMedicine, Volume 6, Number 1:1-8. Okuyemi KS, James AS, Mayo MS, Nollen N, Catley D, Choi WS, Ahluwalia JS.Pathways to health: a cluster randomized trial of nicotine gum and motivationalinterviewing for smoking cessation in low-income housing. Health Educ Behav. 2007Feb;34(1):43-54. Epub 2006 Jun 15. Catley D, Goggin K, Harris KJ, Richter KP, Williams K, Patten C, Resnicow K,Ellerbeck EF, Bradley-Ewing A, Lee HS, Moreno JL, Grobe JE. A Randomized Trial ofMotivational Interviewing: Cessation Induction Among Smokers With Low Desire toQuit. Am J Prev Med. 2016 May;50(5):573-583. doi: 10.1016/j.amepre.2015.10.013.Epub 2015 Dec 23.6
Cultural Diversity and MIMotivational Interviewing Network of Trainers(MINT) represents more than 30 languagesEvidence of increased effectiveness amongethnic minorities (Hettema, Steel & Miller 2005)Examples where MI has been integrated intotreatment protocols include:Peer to peer support in African American churches(Resnicow et al, 2004)Manual for Alaska Native/Native Americancounselors (Grover, Tomlin & Walker, 2005)Treatment for depression among Latinos (Interianet.al, 2010)TTS – Motivational InterviewingPlease maintain this slide. Emphasize that MI is applicable and effectiveacross many cultures.REFERENCESGrover, J., Tomlin, K., Walker, R. D. (2005). Trainer’s Guide to MotivationalInterviewing: Enhancing Motivation for Change-A Learner’s Manual for theAmerican Indian/Alaska Native Counselor. One Sky National American IndianAlaska Native Resource Center.Hettema JE, Miller WR, Steele JM. (2005) A Meta-Analysis of Research onMotivational Interviewing Treatment Effectiveness (MARIMITE). AnnualReview of Clinical Psychology.Interian, A., Martinez, I., et al. (2010) Adaptation of a MotivationalInterviewing Intervention to Improve Antidepressant Adherence AmongLatinos. Cultural Diversity & Ethnic Minority Psychology. 2010;16(2):215-225.Resnicow K, Kramish M, Carr C, et al (2004). Body and soul: a dietaryintervention conducted through African-American churches. AmericanJournal of Preventive Medicine. Volume 27, Issue 2, Pages 97-105.7
Warm‐upExercise8TTS – Motivational Interviewing1) Morning routines2) Structured discussion-1 min: Work life-1 min: summary – sounds interesting tell me more-1 min: response-Switch partners-Discuss in small groups8
Motivational InterviewingMotivational Interviewing is a collaborative conversationstyle for strengthening a person’sown motivation and commitmentto change(Miller & Rollnick, 2013)TTS – Motivational InterviewingMotivational Interviewing is consistent with the style of client-centeredpsychotherapy.It is a directive strategy for talking to clients about resolution ofambivalence and to promote behavior change. MotivationalInterviewing goes well with the “stages of change” model.The purpose is to strengthen the intrinsic motivation to change. If theclient is not motivated to change, behavior change will be moredifficult.99
AmbivalenceA normal part of the change processMay need to be uncoveredEasy to get stuck in ambivalenceGoal: explore both sides and strengthen reasonssupporting changeTTS – Motivational InterviewingHaving mixed feelings is a normal part of human functioning. Everybody hasambivalence except true pre-contemplators. Change is a process in whichpeople move through the stages at different rates.The client has to think about both sides of an issue in order to arguethemselves into a commitment to change. Change is more likely to occurwhen the client experiences the double approach-avoidance conflict (feelingtwo ways about two sides of an issue).Miller and Rollnick suggest that counseling can be considered a method tofacilitate the natural change process. (Miller & Rollnick, 2002).Invite the group to consider how they feel about learning a new skill that wouldrequire them to change their clinical practice.10
MI: The Middle GroundInstructorGuideListenerA.B . .C . *.X.Y.ZTTS – Motivational InterviewingMotivational Interviewing helps the counselor act as a guide: using the bestof listening and the best of instructing. Problems occur with inappropriateuse of instruction.11
Spirit of MI ‐ PACEPartnershipSharing the power and expertiseAcceptanceAutonomy ‐ client makes the decisionAccurate Empathy – understandingAbsolute Worth – lack of judgmentAffirmation – acknowledging strengthsCompassionEvocationInviting the client’s views, knowledge,opinionsTTS– Motivational InterviewingThese concepts are critical to the rapport building in the practice of MI.These concepts are critical to the rapport building in the practice of MI.Exercise: Imagining the back story You are standing in a long line at the grocery store, in a little bit of a hurry. Itseems that someone cut into the line and that person is arguing with another inthe line Describe how you feel – put the feelings aside Imagine some positive story about why that person may have cut inThis mindset helps us to begin to engage with others in the Spirit of MISpirit grows and develops with increasing skill in MI Commitment to learning MI plants the seed Practice promotes the growth12
Partnership/collaborationSharing powerDual expertiseTTS – Motivational InterviewingCollaboration – balances the power between helper and client. Each bring their ownexpertise to the relationship13
athyAbsoluteWorthTTS – Motivational InterviewingAcceptance is a concept that encompasses the aspects of: Autonomy – allowing the client to be empowered to make their owndecisions regarding change Accurate Empathy – striving to understanding and reflecting the issuesfrom the client’s perspective Affirmation – recognizing and describing the client’s strengths and values Absolute Worth – Valuing each client as a worthy human being14
CompassionFocusing on the client’s needsPromoting client’s welfareTTS – Motivational InterviewingWhile compassion has always been implicit in the practice of MI the third edition hasdescribed it explicitly. It illustrates one of the key differences between just using theskills described in MI and truly caring about the client’s wellbeing.15
EvocationInviting the client’s views about Barriers to change Reasons to change Possible solutions andpathways to changeInviting self‐exploration16 InterviewingTTS – Motivational16
MI Non‐AdherentLearning to practice MI includes learningwhat to AVOID:Advising about behavior change withoutpermissionConfronting the patientGiving the patient ordersThere are times and places you might try thesethings, but these behaviors are not consistentwith an MI approach.TTS – Motivational Interviewing17
Guiding PrinciplesResist the righting reflexUnderstand motivationListenEmpower the clientTTS – Motivational Interviewing18
Righting ReflexI think you should You really have to You will feel better You can do it That won’t work Uncle George did fineI feel fine now.No I can’tTTS – Motivational Interviewing19
Understand MotivationExternal motivatorsInternal motivatorsValuesTTS – Motivational InterviewingThe Handout section includes a list of values that may be used with clients.It is only one example of such a list.20
ListenTTS – Motivational Interviewing21
Thomas Gordon’s 12 RoadblocksOrderingWarningGiving TS – Motivational InterviewingRoadblocks get in the way of self-exploration – requires detoursDistracts from listening22
Listen for Change TalkDesire – “I do want to quit someday”Ability – “I can do things that I put my mind to”Reason – “I don’t want my daughter to smokewhen she is an adult”Need – “Smoking is getting pretty expensive”Commitment – “I guess I can smoke outside”DARN‐CTTS – Motivational Interviewing23
Empower the ClientEncourage active participationAcknowledge strengthsShare decision makingTTS – Motivational Interviewing24
Change Talk – DARN/CDesire – “I want to change ”Ability – “I think I can do it ”Reason – “If I change I will be able to ”Need – “If I don’t change ”Commitment – “I will do whatever it takes”TTS – Motivational Interviewing25
A Smoker’s StoryTTS – Motivational InterviewingThis or a similar video can serve as a way of helping participants to identify changetalk amid lots of sustain talk.This video can be downloaded from the dropbox “video” folder.26
Basic SkillsOpen ended questionsAffirmationsReflective listeningSummarizationTTS – Motivational Interviewing27
Open Ended QuestionsCan’t be answered “yes” or “no”Use client’s own wordsHave few assumptionsAsk one questionTTS – Motivational InterviewingOpen ended questions function as door openers that invite the client to talkand create extended conversations. The client can use his/her own words toexplore a topic.How many cigarettes do you smoke?Have you tried to quit before?Are there any reasons why you should quit?Do you understand what I just explained?28
DARN‐C QuestionsD:A:R:N:C:How interested are you in quitting?How might you do it if you decided to quit?What are the three best reasons to quit?How would you feel if you didn’t quit?What do you think you’ll do now?TTS – Motivational Interviewing2929
Affirmation“You are really putting effortinto thinking about this.”“You are working hard atquitting.”“It took a lot for you to gethere today.”TTS – Motivational InterviewingThese statements suggest that the helper notices and affirms clientsstrengths and efforts.What are some of the positive characteristics of your clients? What aresome affirmations you can construct?30
Reflective ListeningGoalsDemonstrate listeningLimit questionsLet the client guide the conversationCapture change talkManage discordTTS – Motivational InterviewingReflective listening reinforces and encourages client verbalization. Theclinician not only listens to what the client is saying, they respond to what isbeing said.31
Communication ComponentsWhat the speaker saysWhat the listener hears21What the speaker means3What the listener thinks it meansTTS – Motivational Interviewing32
ReflectionsWhat the speaker saysWhat the listener hears21What the speaker means3What the listener thinks it meansReflections–checking the meaningTTS – Motivational Interviewing33
ReflectingSimpleRepeating ‐ repeats an element of what the speakerhas said.Rephrasing ‐ substitutes synonyms or slightly rephraseswhat was offered.Paraphrasing – infers meaning in what was said andreflects this back in new words. This adds to andextends what was actually said ‐ like continuing theparagraph that the speaker has been developing sayingthe next sentence rather than repeating the last one.ComplexReflection of feeling ‐ Often regarded as the deepestform of reflection, this is a paraphrase that emphasizesthe emotional dimension through feeling statements,metaphor, etc.TTS – Motivational Interviewing34When practicing provide plenty of examples and encourage the class to take achance with creating deeper reflections.
Thinking ReflectivelySpeaker: Something you should know aboutme .Each Listener: You (are, feel, think) .?Speaker reply: Cold‐‐‐‐Warm‐‐‐HotRotate speakerTTS – Motivational InterviewingExercise: Divide into small groups. Speaker says “something you should know about me is. . . “. Listener responds with a “guess” about the meaning of the speaker’sstatement. Speaker notes whether listener is cold/warm/hot, etc. Each person insmall group takes a turn being speaker. Example: Speaker says “Something you should know about me is that I amconfident.” Listeners say “you are sure of yourself”, “you think you are right mostof the time,” “you know what you are doing,” etc. Speaker notes whether eachlistener is hot/warm/cold, etc. Good idea for presenter to model this by going first, encouraging the group tomake a reflection about their statement.Follow-up exercise:Speaker: Something in my life that I hope would be different in 5 yearsListener – respond only with reflections35
SummarizationLet me see If I understand what you’ve told me so far Ok, this is what I’ve heard so far.Follow up with.Ok, how did I do?What have I missed?Anything you want to correct or add?TTS – Motivational Interviewing36
Focusing the ConversationTTS – Motivational Interviewing37
Agenda MatchingImproving HealthStrategiesStop smokingReducing beforequittingMedicationsTTS – Motivational Interviewing38
EvokingTTS – Motivational Interviewing39
Motivational InterviewingImportance/Confidence1. How important is it for you right now to change? On a scaleof 0 to 10, what number would you give yourself?0 10not atextremelyall importantimportantA. Why are you there and not at 0?B. What would need to happen for you to raise your scorea couple of points?TTS – Motivational Interviewing40
Motivational InterviewingImportance/Confidence2. If you did decide to change, how confident are you that youcould do it?0 10not atextremelyall confidentconfidentA. Why are you there and not at 0?B. What would need to happen for you to raise yourscore a couple of points?TTS – Motivational Interviewing41
Motivational InterviewingQuestion Downward First!Patient actively expresses concernsElicits change talkTTS – Motivational Interviewing42
Responding to Change TalkKeep the conversation going:E: ask for elaboration and examplesA: provide affirmationsR: respond with reflectionsS: SummarizeTTS – Motivational Interviewing43
Recognizing DiscordYes but ArguingPassivityPredicts lack of changeHighly responsive to counselor styleTTS – Motivational InterviewingDiscord has replaced the use of words such as ‘resistance’ and ‘defensiveness’ or‘denial’. These terms place all of the responsibility with the client. Discord allows usto recognize the shared responsibility of client and helper in developing a workingrelationship. Helper language and behavior can help to resolve or at least lessendiscord.44
Avoiding DiscordWrestlingvs.DancingTTS – Motivational Interviewing45
Avoiding DiscordTTS – Motivational Interviewing46
Decreasing DiscordAffirmationsSimple ReflectionsComplex ReflectionsAmplified ReflectionsDouble‐sided ReflectionsTTS – Motivational InterviewingProvide some examples of Amplified and Double-sided Reflections. Include apractice if the group appears ready for this.47
ProcessesPlanningEvokingFocusingEngagingTTS – Motivational InterviewingSome instructors prefer to introduce this earlier in the presentation. It is used hereas a way of reviewing the earlier discussions and identifying how Spirit, Principlesand Skills contribute to each process.This is an appropriate time to reinforce the importance of Engaging, Focusing andEvoking BEFORE moving into planning. Moving too quickly into Planning is acommon occurrence with new TTSs48
Motivational InterviewingPlanning for ActionDesireAbilityReasonNeedActivationTaking StepsCommitmentDARN-CATTTS – Motivational Interviewing4949
Use Action ReflectionsFocus on concrete plansReflect what the client is sayingor implying aboutWhat the plan might beHow the change will be madeTTS – Motivational Interviewing50
Provide Client‐Centered AdviceElicit‐Provide‐ElicitASK PERMISSION FIRST1. ELICITclient’s ideas, needs2. PROVIDE3. ELICITrelevant advice, informationclient’s reactions & commitment to changeTTS – Motivational Interviewing51
Provide Menu of Options“There’s definitely not just oneright way”TTS – Motivational Interviewing52
Wiggle WordsPerhapsMaybeIf you don’t mindOne option isYou might considerHere’s a thought What do you think?TTS – Motivational Interviewing53
Close the DealWhat do you think you will do?Transition to a specific treatment modeProvide referralTTS – Motivational Interviewing54
Motivational InterviewingHow to Learn MI Attend aworkshop Read & learn Practice &listen Get feedback &supervisionTTS – Motivational Interviewing5555
MI ResourcesUMass – Center for Integrated Primary CareOnline courses; Coding and coaching 3: Changing the Conversationhttp://thinkt3.libsyn.com/Talking to Change (on iTunes and Stitcher)Motivational Interviewing Network of Trainerswww.motivationalinterviewing.orgTTS – Motivational InterviewingPlease maintain this slide.56
Basic skills of motivational interviewing How to utilize reflective listening skills Categories of change talk Negotiating an action plan 2. TTS–Motivational Interviewing What is your style? Health Education Model Client‐Centered Therapy Cognitive Be
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Motivational interviewing: Philosophy and Principles 2. Motivational Interviewing: Tools and Techniques 3. Screening and Assessment 4. Brief Intervention Modules 1 and 2 focus on Motivational Interviewing which is a key element of brief intervent
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Exercise: Motivation Interviewing Ruler Why we use Motivational Interviewing Summary of Module 2 Module 3: Motivational Interviewing Skills (Slides 51-81) . . . . 37 Objectives of Module 3 Characteristics of Motivational Interviewing Counseling techniques: OARS Exercise: Role Play-- Open-ended Word Video: Demonstrating O.A.R.S. Exercise: Skill .
