Motivational Interviewing

2013-08-19 18:44:43

Collaboration is a partnership between the therapist and the client, grounded in the point of view and experiences of the client.

This contrasts with some other approaches to substance use disorders treatment, which are based on the therapist assuming an 'expert' role, at times confronting the client and imposing their perpective on the client's substance use behavior and the appropriate course of treatment and outcome.

The MI approach is one of the therapist's drawing out the individual's own thoughts and ideas, rather than imposing their opinions as motivation and commitment to change is most powerful and durable when it comes from the client. No matter what reasons the therapist might offer to convince the client of the need to change ge their behavior or how much they

might want the person to do so, lasting change is more likely to occur when the client discovers their own reasons and determination to change. The therapist's job is to "draw out" the person's own motivations and skills for change, not to tell them what to do or why they should do.

Unlike some other treatment models that emphasize the clinician as an authority figure, Motivational Interviewing recognizes that the true power for change rests within the client. Ultimately, it is up to the individual to follow through

with making changes happen. This is empowering to the individual, but also gives them responsibility for their actions.

Counselors reinforce that there is no single "right way" to change and that there are multiple ways that change can occur. In addition to deciding whether they will make a change, clients are encouraged to take the lead in developing a menu of options as to how to achieve the desired change.

The Principles of Motivational Interviewing

Building on and bringing to life the elements of the MI style , there are four distinct principles

that guide the practice of MI. The therapist employing MI will hold true to these principles

throughout treatment.

Express Empathy

Empathy involves seeing the world through the client's eyes, thinking about things as the

client thinks about them, feeling things as the client feels them, sharing in the client's

experiences. This approach provides the basis for clients to be heard and understood, and

in turn, clients are more likely to honestly share their experiences in depth. The process of

expressing empathy relies on the client s experiencing the counselor as able to see the

world as they (the client) sees it.

Support Self- ‐Efficacy

MI is a strengths- ‐based approach that believes that clients have within themselves the

capabilities to change successfully. A client's belief that change is possible (self- ‐efficacy) is

needed to instill hope about making those difficult changes. Clients often have previously

tried and been unable to achieve or maintain the desired change, creating doubt about

their ability to succeed. In Motivational Interviewing, counselors support self- ‐efficacy by

focusing on previous successes and highlighting skills and strengths that the client already

has.

Roll with Resistance

From an MI perspective, resistance in treatment occurs when then the client experiences a

conflict between their view of the problem or the solution and that of the clinician or

when the client experiences their freedom or autonomy being impinged upon. These

experiences are often based in the client s ambivalence about change. In MI, counselors

avoid eliciting resistance by not confronting the client and when resistance occurs, they

work to de- ‐escalate and avoid a negative interaction, instead "rolling with it." Actions and

statements that demonstrate resistance remain unchallenged especially early in the

counseling relationship. By rolling with resistance, it disrupts any struggle that may occur

and the session does not resemble an argument or the client s playing "devil's advocate" or

yes, but to the counselor's suggestions. The MI value on having the client define the

problem and develop their own solutions leaves little for the client to resist. A frequently

used metaphor is dancing rather than wrestling with the client. In exploring client

concerns, counselors invite clients to examine new points of view, and are careful not to

impose their own ways of thinking. A key concept is that counselor s avoid the righting

reflex , a tendency born from concern, to ensure that the client understands and agrees

with the need to change and to solve the problem for the client.

Develop Discrepancy

Motivation for change occurs when people perceive a mismatch between where they are

and where they want to be , and a counselor practicing Motivational Interviewing works to

develop this by helping clients examine the discrepancies between their current

circumstances/behavior and their values and future goals. When clients recognize that

their current behaviors place them in conflict with their values or interfere with

accomplishment of self- ‐identified goals, they are more likely to experience increased

motivation to make important life changes. It is important that the counselor using MI does

not use strategies to develop discrepancy at the expense of the other principles, yet

gradually help clients to become aware of how current behaviors may lead them away

from, rather than toward, their important goals.

Motivational Interviewing Skills and Strategies

The practice of Motivational Interviewing involves the skillful use of certain techniques for

bringing to life the MI spirit , demonstrating the MI principles, and guiding the process toward

eliciting client change talk and commitment for change. Change talk involves statements or

non- ‐verbal communications indicating the client may be considering the possibility of change.

OARS

Often called micro counseling skills, OARS is a brief way to remember the basic approach used

in Motivational Interviewing. Open Ended Questions, Affirmations, Reflections, and

Summaries are core counselor behaviors employed to move the process forward by

establishing a therapeutic alliance and eliciting discussion about change.

Open- ‐ended questions are those that are not easily answered with a "yes/no" or short

answer containing only a specific, limited piece of information. Open- ‐ended questions invite

elaboration and thinking more deeply about an issue. Although closed questions have their

place and are at times valuable (e.g., when collecting specific information in an assessment),

open- ‐ended questions create forward momentum used to help the client explore the

reasons for and possibility of change.

Affirmations are statements that recognize client strengths. They assist in building rapport

and in helping the client see themselves in a different, more positive light. To be effective

they must be congruent and genuine. The use of affirmations can help clients feel that

change is possible even when previous efforts have been unsuccessful. Affirmations often

involve reframing behaviors or concerns as evidence of positive client qualities. Affirmations

are a key element in facilitating the MI principle of Supporting Self- ‐efficacy.

Reflections or reflective listening is perhaps the most crucial skill in Motivational

Interviewing. It has two primary purposes. First is to bring to life the principle of Expressing

Empathy. By careful listening and reflective responses, the client comes to feel that the

counselor understands the issues from their perspective. Beyond this, strategic use

reflective listening is a core intervention toward guiding the client toward change,

supporting the goal- ‐directed aspect of MI. In this use of reflections, the therapist guides the

client towards resolving ambivalence by a focus on the negative aspects of the status quo

and the positives of making change. There are several levels of reflection ranging from

simple to more complex. Different types of reflections are skillfully used as clients

demonstrate different levels of readiness for change. For example, some types of

reflections are more helpful when the client seems resistant and others more appropriate

when the client offers statements more indicative of commitment to change.

Summaries are a special type of reflection where the therapist recaps what has occurred in

all or part of a counseling session(s). Summaries communicate interest, understanding and

call attention to important elements of the discussion. They may be used to shift attention

or direction and prepare the client to move on. Summaries can highlight both sides of a

client s ambivalence about change and promote the development of discrepancy by

strategically selecting what information should be included and what can be minimized or

excluded.

Change Talk

Change talk is defined as statements by the client revealing consideration of, motivation for, or

commitment to change. In Motivational Interviewing, the therapist seeks to guide the client to

expressions of change talk as the pathway to change. Research indicates a clear correlation

between client statements about change and outcomes - ‐ client- ‐reported levels of success in

changing a behavior. The more someone talks about change, the more likely they are to

change. Different types of change talk can be described using the mnemonic DARN- ‐CAT.

Preparatory Change Talk

Desire (I want to change)

Ability (I can change)

Reason (It s important to change)

Need (I should change)

And most predictive of positive outcome:

Implementing Change Talk

Commitment (I will make changes)

Activation (I am ready, prepared, willing to change)

Taking Steps (I am taking specific actions to change)

Strategies for Evoking Change Talk

There are specific therapeutic strategies that are likely to elicit and support change talk in

Motivational Interviewing:

1. Ask Evocative Questions: Ask an open question, the answer to which is likely to be change

talk.

2. Explore Decisional Balance: Ask for the pros and cons of both changing and staying the

same.

3. Good Things/Not- ‐So- ‐Good Things: Ask about the positives and negatives of the target

behavior.

4. Ask for Elaboration/Examples: When a change talk theme emerges, ask for more details.

In what ways? Tell me more? What does that look like? When was the last time that

happened?

5. Look Back: Ask about a time before the target behavior emerged. How were things better,

different?

6. Look Forward: Ask what may happen if things continue as they are (status quo). Try the

miracle question: If you were 100% successful in making the changes you want, what would

be different? How would you like your life to be five years from now?

7. Query Extremes: What are the worst things that might happen if you don t make this

change? What are the best things that might happen if you do make this change?

8. Use Change Rulers: Ask: On a scale from 1 to 10, how important is it to you to change [the

specific target behavior] where 1 is not at all important, and a 10 is extremely important?

Follow up: And why are you at ___and not _____ [a lower number than stated]? What

might happen that could move you from ___ to [a higher number]?

Alternatively, you could also ask How confident are that you could make the change if you

decided to do it?

9. Explore Goals and Values: Ask what the person s guiding values are. What do they want in

life? Using a values card sort activity can be helpful here. Ask how the continuation of target

behavior fits in with the person s goals or values. Does it help realize an important goal or

value, interfere with it, or is it irrelevant?

10. Come Alongside: Explicitly side with the negative (status quo) side of ambivalence.

Perhaps _______is so important to you that you won t give it up, no matter what the cost.