Motivational InterviewingEngaging clients in a conversation about change

16th Annual Social Work ConferenceUniversity of Southern IndianaMarch 2nd, 2018Chad Connor, MSSW, LCSW

So what is Motivational Interviewing?

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"…a person-centered counseling style for addressing the common problem of ambivalence about change." (Miller & Rollnick, 2013)

Motivational interviewing is…

MI is a COLLABORATIVE

conversation about CHANGE

A Taste of MI(Miller & Rollnick, 2013)

Volunteer needs to be willing to share:

Something you want / need to change, but have not yet (ambivalent about it)

Should be something you’re willing to share with a complete stranger

I need a volunteer to be my client!

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Which style did you prefer?

Style 1

Highly directive

Clinician "driving the bus“

"Righting reflex"

Statistic re: response to this style

Style 2

Spirit of MI

Conversational

Questions have strategic purpose / elicit responses

from client

Client is put in the role of expert of their own situation

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“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 the false statements as trust deepens.”

Carl Rogers and Ruth Sanford

Today’s Objectives

You will understand the values and basic techniques used in MI

You will understand MI’s application to social work practice across various client populations and presenting problems

You will know what to do to further your training / proficiency in MI

Spirit of MI

More than technique, MI is person-centered

Derivative of the work of Carl Rogers

Client is in control of making their own decisions

Relationship is collaborative, built on mutual trust

8Carl Rogers

A Continuum of Communication Styles

(Miller & Rollnick, 2013)

Directing Guiding Following

Spirit of MI

(Miller & Rollnick, 2013)

Social Work Values(NASW, 2017)

ServiceSocialJustice

Dignity And

Worth

HumanRelation

ships

IntegrityCompetence

(NASW, 2017)

(NASW, 2017)

(NASW, 2017)

Congruence with Social Work (table seen in Hohman, 2012, page 7)

Traditional Style VS Motivational Interviewing

Traditional

Clinician as expert

"Righting reflex" / Heavy advice giving

Clinician does much of the talking

"I have the answer and I am going to give it to you"

Motivational Interviewing

Client as expert

Eliciting and reinforcing client's change talk / Conversational yet strategic

Client does 50% or more of talking

"You probably know what you want to change, can decide what to change or not change and, together we can help you become "unstuck"

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"Righting Reflex" often isn’t the right reflex for our

clients

As professional helpers, we have the tendency to ‘rescue’ others

"Don't do that, there is a better way!”

" If I can persuade them, they will see that they need to do something different.“

The “Righting Reflex” can lead our clients to following experiences:

Need to explain / defend self

"I am not being understood"

Shame or anger

"What's the point of meeting with you?“

“I know this already!”

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You can arrange the conversation so that people talk themselves into change based on their own values and interests…

Motivation is NOT stable, it is fluid and can be changed!

The way you talk to clients about health, changing beliefs, feelings, attitudes can substantially influence motivation to change and maintain change.

Persuasion (i.e. use of logical arguments) does not work nearly as well as we might think!

Whether change happens is a person's choice. We cannot take this away not matter how hard we try.

* Angela R. Bethea, Ph.D., 2015

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Challenging the Myth of the Unmotivated Client*

(Miller & Rollnick, 2013 )

Most people know what they need / want to change (why logical arguments fail)

"Decisional balance“ There are reasons for a person to

sustain behavior

There are reasons to change targeted behavior

This is a NORMAL experience

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What prevents our clients from

making the changes they

need to make?

Ambivalence("I want to change AND I don't want to change")

There are things we can do to get our clients thinking about change….or think about sustain.

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CHANGE

SUSTAIN

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We CAN influence how clients talk about change

There are things WE can do to encourage two types of talk about target behavior

• CHANGE talk

• SUSTAIN talk

Research supports the idea that if we can get our clients talk about their own reasons for change, they are more likely to move toward making that change

Is it Change Talk?

Change

I cut back on how many beers I drink

I need to stop hanging around THOSE people

I guess I could give those meetings a try

I know this stuff is going to kill me

Sustain

I don’t have a drinking problem

It’s impossible to stop when it is so easily available

Nothing will help me stop

Why change? Something’s going to kill me anyway, right?

DARN CATS (the way we talk about change)

Desire

Ability

Reasons

Need

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Miller & Rollnick, 2013

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Commitment

Action

Taking Steps

DARN CATS (the way we talk about change)

Miller & Rollnick, 2013

Do you remember the

questions asked in the

role play?

They are DARN questions –examples of ways to draw

our change talk from clients

1.“Why would you want to make this change?” (Desire)

2.“How might you go about it in order to succeed?” (Ability)

3.“What are the 3 best reasons to do it, and why?” (Reasons)

4.“On a scale from 0 to 10, how important would you say it is for you to make this change?” (Need)

My last question:

“So what do you think you will do?” (CATS question

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What can you do to elicit change talk?

“What people really need is a

good listening to.”

Mary Lou Casey

Informing / Advising

OARS

DARN CATS

1. Engaging

2. Focusing

3. Evoking

4. Planning

MI’s Four ProcessesNot necessarily linear*

Miller & Rollnick, 2013

Engaging

Self-determination, collaboration, active listening, mutual

trust

Focusing

Identifying a target behavior, listing concerns, clarifying

direction, developing discrepancies

Evoking

Eliciting and strengthening change talk, avoid / reduce

sustain talk

Planning

Commitment to change, action planning

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Engaging, Focusing and Evoking processes of MI must be present to do MI.

If you are using the skills (reflections, open-ended questions) without initiating a trusting, collaborative approach with your client, it is NOT MI. (Engaging)

If you do not have a behaviorally specific change that is the focus of your work, it is NOT MI. (Focusing)

If you do the above, yet are not concerned with eliciting the client’s own reasons to change, it is NOT MI (Evoking)

MI’s essential ingredients

Miller & Rollnick, 2013

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But what about Planning?

Miller & Rollnick, 2013

You CAN do MI without getting to the point of engaging in the Planning process

MI is concerned with moving the client forward past ambivalence and through the stages of change

Pre-contemplation Contemplation

Contemplation Preparation

Pre-contemplation Action

Successful

MI!

MI versus non-MI skills & behaviors (Miller and Rollnick, 2013)

Advise w/ permission

Affirm

Emphasize Control

Open Question

Reflect

Reframe

Support

Advise without permission

Confront

Direct

Raise concern without permission

Warn

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MI-adherence responses (MI-A) MI-Non Adherent Responses (MI-NA)

OARS

OARSOpen ended questions

Affirmations

Reflections

Summaries

• The vehicle for change

• The core skills used in MI

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Open vs Closed Ended Questions Do you want to stop using marijuana?

VS.

What are some reasons you might have for not using marijuana?

Be careful not to ask too many in rapid succession – can come across as being interrogated!

MI adheres to the strategy of providing at least 2-3 reflections for each question…

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Open Ended Questions

Affirmations

Verbal recognition and praise of the client’s talk of change

Example: Client: I am thinking about looking into women’s shelters so I have somewhere to

go if I decide to leave Bill.

You: That’s great. It must take a lot of courage to take this first step.

Encourage and solidify the client’s talk about change by affirming them when you recognize change talk.

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Reflections

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Conveys active listening and engagement

Allows the client to hear their own talk of change through your reflections

Strategic use of reflection can be used to move a conversation forward or put the client in a position to defend the need to change. (Complex reflection)

Example:

Client: Getting high makes all my problems go away (sustain talk)

You: Smoking makes life easier to deal with, so your life is ok if you continue to smoke.

Client: Nah, well, sort of. My problems feel like they go away when I smoke, but DCS is involved now and I have to do something different I

guess (change talk)

You: On the one hand, smoking is how you have dealt with things, but because DCS is involved now, you have to figure out another way to deal with things. What have you tried before to deal with your problems?

Miller and Rollnick, 2013

Deepening Reflections(simple, amplified, double-sided, metaphor)

1. It’s been fun, but something has got to give. I just can’t go on like this anymore.

2. I’ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work, except having a couple drinks.

3. I’ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work –except having a couple of drinks.

4. So, I’m not too worried, but its been over a year since I’ve had an HIV test.

5. I know I’m not perfect, but why do they have to always tell me what to do. I’m not 3!

Summaries

• Use these at strategic times to “collect” all the change talk statements the client has made and feed back to them to hear their own change talk.

• Can be used after a series of reflections and statements from the client to follow up with a new open-ended question (remember, 3-4 reflections for each open ended question is strongly encouraged)

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Example:You: “Let me just make sure I am understanding your thinking at this time. On the one hand, you

and your husband have been together for 10 years, but the fighting has gotten so bad that you are not sure how long you can go on like this. You worry that co-workers have noticed your bruises and you are concerned it is getting worse. You are scared to be alone, but you do have a good friend that said she will help you stay on your feet while you go to a shelter if you decide to do that. On a scale of 0 to 10, how important to you is it that you leave your husband?”

Stephen Rollnick, Ph.D

Now that I know a

little about MI, with

whom do I use it?

Anywhere there might be ambivalence to changing a behavior

MI requires a specific target behavior

Addiction

Relationships

Leaving a partner?

Service engagement

Diet / weight loss

Smoking cessation

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Assessments "MI Sandwich“

MI (5-10 mins) ----> Assessment / Data Collection ----> MI-style feedback (10-5 mins)

MI to engage client / explore reason for referral

MI at end to elicit response to assessment, data collect, explore ambivalence and readiness for change.

Can provide advice (with permission!)

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How can I work it in non-

counseling / therapy

settings?

Where do I learn more?

The MI "bible" Authors & Founders: William Miller &

Steve Rollnick, 2013

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Where do I learn more?

For exercises / practice…

Where do I learn more?

FREE at samhsa.gov

MINT (Motivational Interviewing International Network of Trainers)

Website (www.motivationinterviewing.org)

Trainings

Formal supervision from MINT trainers

MITI

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Where do I learn more?

References

Bethea, A.R. (2015, December). Introduction to motivational interviewing. Lecture presented at 2-day continuing education seminar, Atlanta, GA.

Hohman, M. (2012). Motivational interviewing in social work practice. New York: The Guilford Press.

Miller, W.R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: The Guilford Press.

National Association of Social Workers. (2017). Code of ethics of the National Association of Social Workers. Washington, DC. NASW Press.

Rosengren, D.B. (2009). Building motivational interviewing skills: A practitioner workbook (1st ed.). New York: The Guilford Press