## Metadata - Author: [[William Miller]], [[Stephen Rollnick]], [[Theresa Moyers]] - Full Title: Motivational Interviewing – Foundational - Topics: [[Coaching (Index)]], [[Mental Health]], [[Motivation]] - Link: https://psychwire.com/motivational-interviewing - Category: #course ## Summary * Motivational interviewing (MI) is a particular way of having a **conversation about personal change**. It attempts to evoke and strengthen a **person’s own motivations and commitment to change**. * MI is a **person-centered approach** in the tradition of Carl Rogers. At its heart, it assumes that people have a **self-actualizing tendency** and **move towards flourishing** given the right conditions. * MI is particularly helpful if a person is **ambivalent about change** – they both want and don’t want to change. * Many helpers have a **righting reflex** – they want to jump in and fix another person and solve their problems for them. This is often counterproductive and triggers **reactance** in the person being “helped”. * MI has four processes: Engaging, Focusing, Evoking, and Planning. * **Engaging**, the first process of MI, is about developing a **trusting relationship** with the client through **genuine listening**. Curiosity and a desire to understand is the driver of good listening. * **Empathy** is the ability to accurately perceive the world view of the client. It’s one of the best predictors of therapy outcomes. * There are four fundamental **engaging skills**, abbreviated as “**OARS**”: * **Open questions**: Open as opposed to closed questions tend to invite more exploration from the client. * **Affirmations**: Notice and comment genuinely on positive aspects of the client. It helps the person internalize a strength or quality. * **Reflections**: Give back to the person what you have understood of what they said in the form of a statement. It invites further sharing and is less threatening than questions. * **Summaries**: Pull together several things that the client has said at various points in the conversation. It helps focus the conversation and shows that you’re listening. * **Focusing**, the second process of MI, is about agreeing on a **direction and goal for the conversation** together with the client. Lay out the options and make a joint decision about what to focus on. * **Evoking**, the third process of MI, calls forth the client’s own **motivations for and ideas about change**. With a focus in place, evoking helps the client get clear on why they want to make that change. It helps the person move themselves towards change. * **Change talk** is anything the client says that moves them towards change. **Sustain talk**, on the other hand, is talk that favours the status quo. Research suggests that **change talk predicts actual change**. Your job is to strengthen change talk and soften sustain talk, and to move the balance in the direction of greater frequency and strength of change talk. * **Preparatory change talk** is when the person is considering change. There are four kinds, abbreviated as “**DARN**”: * **Desire**: Why they want to make the change * **Ability**: How they could do it * **Reasons**: Good reasons for making the change * **Need**: Why it’s important and urgent to make the change * **Mobilizing change talk** appears as the person gets closer to making a change. The acronym “**CATS**” captures the different kinds: * **Commitment**: What they intend to do * **Activation**: What they are ready or willing to do * **Taking Steps**: What they have already done * Importance and confidence are different motivational issues. **Importance** is how much motivation the person has to make a change. **Confidence** is their belief in their ability to make the change. People are unwilling to think that something is important if they believe they can’t do it. * **Planning**, the fourth and last process of MI, moves towards **how to make the change**. It’s an **agreement about concrete next steps**. Don’t force a plan if the person isn’t there yet. * First, prepare a summary of the change talk they offered. * Then, ask “So what do you think you’ll do?” or “What’s next?” * Offer advice using the **Elicit – Provide – Elicit** framework: First, find out what they already know or would like to know. Follow up on the advice by asking them what they make of the information you provided. %% ## 1. Introduction of the Clinical Method * **Summary:** * **Persuasion**: Why don’t people do what we tell them to do? **Many helping professionals feel a “righting reflex” to fix their clients’ problems.** Sometimes advice can be helpful, but if you find yourself trying to persuade people to change while they make “Yes, but . .” responses, you’re in a losing struggle. **Most people are ambivalent about change, and if you argue for change, the natural response is to defend the other side of the ambivalence, to argue against change.** **People learn what they believe as they hear themselves talk, and become more committed to what they themselves say.** In fact, psychological reactance is the well-documented tendency of people to not do what they are told (or do the opposite), even when they agree with the advice. **Ultimately it is your clients who will determine whether and how to change.** You cannot make those decisions for them. * **Conversations about change**: **Motivational interviewing (MI) is a particular way of having a conversation about change, to strengthen the person’s own motivations and commitment to change.** It is not about “installing” motivation or trying to give people something that they lack. Rather MI evokes what is already there in your clients – their own reasons, values, and ideas for how to change. Specific ways for doing this are covered in subsequent weeks, but it is important to understand the underlying mindset and “heartset” with which MI is practiced. MI is not a technique for tricking people into changing. Four elements of the underlying spirit of MI are: Collaboration, Acceptance, Compassion, and Evocation. * **Four processes**: Week 1 has also provided an overview of the four processes comprising MI. The first of these is Engaging – developing a trusting, working relationship by understanding a client’s own perspective, and communicating what you understand back to your clients. Focusing is about clarifying shared goals, which gives direction to your work. Evoking is the process that is most unique to MI; it helps clients to verbalize and strengthen their own motivations for change. Finally, the planning process explores the “how” of change, developing at least the first steps to reach the focal goals for change. These sound like linear steps, but they don’t necessarily happen in order, and MI involves moving flexibly among the four processes. * **Motivational Interviewing**: **A particular way to have a conversation about personal change.** **A person-centered approach built on the work of Carl Rogers.** It’s focused on the person and their motivations. MI adds a particular direction and focus that’s agreed upon with the client. MI is a purposeful conversation about change. You help someone make a decision about what’s healthy and fulfilling for them. * **What makes for a conversation that’s helpful or not helpful?** * **What makes for a good and effective helper?** * **Ambivalence**: **People often feel two ways about change, with conflicting voices and forces.** It’s normal to simultaneously want and not want something. Ambivalence is uncomfortable, so people want to avoid it. * MI is often only 1-2 sessions. It’s short because the person already has the means within them to make the change, but they are stuck in ambivalence and a lack of motivation. What you’re after is resolving the ambivalence, and they’ll do the rest. * **Skip the intake interview, and directly do something that will help them even if they don’t come back.** You sense during the first session whether another one would be helpful. * **Persuasion**: **A normal reaction to persuasion is psychological reactance. When you give someone advice, they typically don’t do it, or do the opposite** — even if they agree with you. They talk themselves out of changing. Common responses to persuasion: * 1) They feel **disrespected** and one down. * 2) They feel **defensive** and push back. * 3) They want to **withdraw** and leave. * **“Yes, but” response**: A typical response to someone else giving you advice. When a person is ambivalent, they are particularly unreceptive to advice and direction. * **The righting reflex**: **You automatically see and solve a problem for someone else. You jump in and rescue them.** Effects: * 1) It taints the relationship. * 2) It leads to poor outcomes. * Why do people resist advice? * They feel like their **autonomy is being undermined**. Power hierarchies. * The client is the person in charge. You don’t get to make their decisions. Start by yielding. “You’re in charge, whether you get to make any changes is up to you.” * They **distrust the person giving advice**. * You’re **not really connected with the person**. * **A taste of MI exercise**: * 1. Why would you want to make this change? * 2. If you did decide to do it, how might you go about it in order to succeed? * 3. What would you say are the three best reasons for you to do it? * 4. On a scale from zero to ten, how important would you say it is for you to make this change, if 0 means “not at all important” and 10 means “the most important thing in my life right now”? What number would you say? * 4a.Then, when you hear the number, ask: And why are you at ___ and not zero? If you have reflective listening skills, use them as the person answers each question, reflecting what was said and remembering it. * 5. So what do you think you’ll do? * Effects: * They feel heard instead of disrespected * They feel optimistic about being able to make the change * They open up instead of feeling defensive * They want to come back instead of wanting to run away * **Mindset/Spirit of MI**: This is the place from which your behaviors and techniques flow. **Humans have inside of them a tendency to move towards flourishing and well-being (actualising tendency assumption).** There are mutual feedback loops between the attitude/spirit and behavior/technique. If the spirit is there, you’ll be okay. If you use the wrong technique but have an attitude of curiosity, it will work. People forgive your mistakes if they feel you care. * **Collaboration** with the client * **Acceptance** of the client * **Evocation** from the client * **Compassion** for the client * **Lifting the burden of change**: **You’re not the expert there to fix the person.** You don’t have to make the person change — you can’t. You don’t have to come up with the good ideas. * **Guiding**: MI is in the middle of “directing” and “following” — it’s “guiding”. * Resistive clients: If you practice MI, you don’t get much resistance. That’s why MI works particularly well with “resistive” clients. * **The Four Processes of MI**: These processes don’t have to be linear. You’re moving flexibly among these processes. * **Engaging**: Building an alliance and a working relationship with your client * **Focusing**: Coming to a shared idea about the main focus * **Evoking**: Bringing out the client’s own arguments for change * **Planning**: The client is willing to envision change and how they go about making it ## 2. The Engaging Process * **Summary**: * **Engaging & OARS**: **Engaging skills help to develop a trusting therapeutic alliance that serves as a foundation for the other three processes of MI.** This doesn’t require a long time; in fact, signs of engaging may begin to appear within a few minutes of quality listening. The important thing to remember is to **begin with Engaging, rather than charging ahead into fact gathering or planning.** * **Open-ended Questions**: Four fundamental skills in the Engaging process are summarized in the acronym OARS: Open questions, Affirmation, Reflection, and Summaries. In this week we focused on two of these skills: Open questions, and Reflection. A closed question is one that asks for a short answer like Yes or No, a specific piece of information, or a multiple choice. Open questions, in contrast, leave the person room to consider and talk freely. Open questions followed by reflective listening is a common combination in MI. * **Reflection**: The simple but not easy skill of reflective listening is fundamental in MI. **It is the ability to accurately perceive another’s world view, and to share and test your understanding.** In MI, empathic listening is important in all four processes. Simple reflections echo what the person has said without adding much to it, where complex reflections make a guess about the person’s meaning without asking a question. **A good ratio of reflections to questions in MI is 2:1; two reflections per question asked. Posing too many questions, particularly closed questions, tends to put the client in a passive role.** This skill has therapeutic value in itself; it is associated with better client outcomes across a broad range of helping relationships. * **The process of engaging in MI is the method of forming a relationship of trust with your client through genuine listening.** * The skill in engaging is leaving everything aside and simply listening. * **Success in therapy is not so much about the content of what you do, but _how_ you do it. The quality of the relationship is the most important determinant of good outcomes.** * **Fundamental skills of engaging:** **OARS** * O - Open-ended questions * A - Affirmations: share something you appreciate, a strength you notice * R - Reflections: reflective listening, offer a guess about what they are saying * S - Summaries: let them know that you’ve been following * **Open and Closed Questions**: * A closed question constrains the range of responses. It controls what the other person can say. * Yes or no questions, multiple choice questions * Asking for specific information, fact gathering * An open question encourages clients to explore their own internal experiences as they’re speaking with you. It invites more sharing. * Using open questions signals interest. * **Intake session**: **Skip the initial information gathering. You can help them without having much context. Start immediately with engaging.** Fact-gathering places the client in a passive position. But you want an active, engaged client. What do you really have to know in the first session? * They start with “Tell me what brings you here, what concerns you, and how you think we might be able to help.” * **Empathy**: **Your ability to accurately perceive the world view of your client. Accurate reflective listening. You can increase your capacity for empathy through practice.** Empathy doesn’t mean agreement or sympathy. It’s simply about understanding your client’s perspective and being able to convey it back to them. * **Accurate empathy**: **Empathy predicts treatment outcomes across a variety of different behaviors. When measured accurately, it’s hard to find anything that better predicts outcomes than empathy. Low therapist empathy has been shown to lead to outcomes worse than no treatment.** However, many therapists have low empathy relative to their amount of therapy experience. * **Thomas Gordon's 12 Roadblocks to Listening** (in the sense of empathic understanding): Thomas Gordon was a student of Carl Rogers. * 1. Ordering, directing * 2. Warning, threatening * 3. Giving advice, making suggestions, providing solutions * 4. Persuading with logic, arguing, lecturing * 5. Moralizing, preaching * 6. Judging, criticizing, blaming * 7. Agreeing, providing, praising * 8. Shaming, ridiculing, name-calling * 9. Interpreting, analyzing * 10. Reasoning, sympathizing * 11. Questioning, probing * 12. Withdrawing, distracting, humoring, changing the subject * Can people learn to listen? * **Curiosity is the driver of good listening.** * You need an uncluttered mind, letting go of what you think you knew. * **Being a good listener is about making reflective statements, it’s an active process.** * **Body language**: * Be natural and authentic. * Keep an open posture. * The purpose of reflection in MI is to encourage the person to consider change. **Reflect in a way such that the person’s gaze is focused on change.** * **Reflection skills**: **Giving back to the person what you have understood of what they said.** * **It’s essentially a guess, a hypothesis about what might be going on.** * **Use reflective listening as a safety net that you can come back to at any point.** * There are various filters in communication between two people that introduce the potential for error and miscommunication. * Don’t respond to what you think you believe the word you heard meant. It could be wrong in various ways. * “Here’s what I heard” * **This helps you understand what the client is actually experiencing.** * **This helps the client better understand what’s going on for them.** * **Simple reflections**: **Stay close to what the person said. Say back what they said without messing much with it.** The essence of a simple reflection is “I got what you said, now tell me some more”. You don’t take much of a risk. This is a beginning step. * **Reflections are statements. Your voice goes down at the end.** * To turn a question into a reflection: * Remove the question words at the beginning — e.g., “do you mean…” * Turn down the voice at the end of the sentence. * **Statements are less threatening than questions. Asking a question puts pressure on the person.** Somehow, reflections help surface more information and the person is more likely to keep going. * **Guessing**: You’re making a guess about what it is the person meant. The person can either confirm or deny. Either way, you communicate that you’re really listening, and you move the work forward. * **Complex Reflections**: **You reflect something that’s unsaid, but not too far below the surface.** You take something the person didn’t quite say, but might well have said. **You take a risk and make a small interpretation of what the person says. It creates more momentum.** Complex reflections also build the working alliance. * **Reflect the underlying feeling**: Instead of saying back the content, you comment on the feeling that might be underneath it. * **Continuing the paragraph**: Rather than saying again what they just said, say what could be the next sentence in the paragraph. * **Reframing**: Suggest a slightly different meaning to what the person has just said. It’s a different interpretation. It’s a little more assertive form of reflection. * **Double-sided reflection**: When the person is feeling two ways about something and is ambivalent. It captures both sides of what the person is saying at the same time. “X _and_ Y”. Don’t say “X _but_ Y”, because “but” diminishes what comes before it. * **Sustained reflection**: Stay in reflection. Keep reflecting over time and following where the person is going. Help the person explore their experience without messing with it. * **Amplified reflection**: Amplify and extend how the person might be feeling. Often, they push back and go deeper. * Starting point: **Practice capturing the essence of what someone is saying, and give it back to them. Stick with the curious mind frame and a desire to understand.** ## 3. Using OARS and Focusing * **Summary:** * **Affirmations**: **Affirming involves noticing and commenting genuinely on positive aspects of your clients, particularly their strengths.** Simple affirmations offer support or encouragement regarding clients’ efforts and experiences. Complex affirmations comment on something positive and enduring about the client, such as an evident strength. * **Summaries**: **Summaries pull together several things that a client has told you. This communicates that you have been listening to and remember what clients tell you.** These OARS skills are foundational in the Engaging process, but are also used throughout the Focusing, Evoking, and Planning processes as well. * **Neutrality**: Being careful not to steer clients in one particularly direction, even inadvertently. We described decisional balance as a way to keep your balance when you choose to remain neutral. Decisional balance is contraindicated, however, when you are helping a client to resolve ambivalence in a particular direction toward change. * **Focusing**: The second process of MI (after Engaging). **Focusing clarifies the direction for your work together by developing shared goals toward which to move.** In this sense, **MI is directional (it has momentum toward goals) but not directive (with the counselor telling the client what to do).** Agenda Mapping is a particular method for finding a focus among multiple possible goals or directions for change. * **Affirmations**: **Something reassuring or encouraging or some strength of your client that you notice and communicate back to them**, rather than to have it remain unsaid or unnoticed. Affirmations should be real and genuine from your perspective. Try to find something you like about the clients you work with. * **The impact of affirmations**: Using affirmations is an expression of an attitude. It suggests that you see the client as a human being with strengths. **Affirmations help people internalise a strength or quality.** A good time to use affirmations is if someone is struggling. * **Simple affirmations**: Positive and encouraging. “It’s good to see you”, or “that’s great!”. Such affirmations are easy to use and a good place to begin. However, overusing them may make you look shallow and disingenuous. They also tend to keep conversations at a shallow level. * **Complex affirmations**: Accentuate something positive about the client. Include information about their strengths, their accomplishments, their intentions and efforts. Try to move from simple to complex affirmations as you get to know the client. * **Summaries**: **Summaries are a specific type of reflection. A summary pulls together things that a person has said.** It communicates to the client "What you tell me is so important that I remember it". Summaries can be used at various points in the session. Summaries can also be used when transitioning from one topic to another. * Throughout the session: “So far you’ve told me…. What else?” * Towards the end of the session: Follow it up with “Is there something else that I’ve missed?” * **Neutrality**: **Not steering the conversation in one direction or another. Neutrality is staying out of the decision process while it’s being made.** Make a conscious choice whether you’re trying to move them in a particular direction (usually because that’s what they’ve asked you to do) or not. For instance, if somebody is experiencing bereavement, simply be with them. Some of neutrality is also about not getting too invested in outcomes. * **Direction or neutrality**: No two therapists will agree on this. Which option they’ll choose depends on their personal value systems, experience, etc. MI doesn’t tell you when you should become directional and when to remain neutral. * **Decisional balance**: **Weigh up the pros and cons in a neutral way. Ask what the “good things” (benefits) and “not good things” (costs) are about how things are now (not changing) and if they made a change.** Ask questions about all four quadrants, but don’t emphasise any particular quadrant. Use the OARS skills in each of the four quadrants. If you do the decisional balance process properly, you’ve equally evoked change talk and sustain talk. The expected outcome would be ambivalence. **If you do a decisional balance with people who are ambivalent, their commitment to change goes down and they get even more stuck.** Do this when you want to stay out of the decision but help them reach a decision. * However this tool can also be useful in a more MI consistent manner. By filling out the quadrants “benefits of changing”, “cons and costs of not changing”, you are making an argument for change. This is a useful practical tool if you are finding it challenging to discuss change with your client. * **Focusing**: The second process of MI. **Focusing is when you come together with a shared idea of what your goals should be. The focus is your direction. It’s a negotiated process that you both want to agree about.** What is the shared topic of our interest together? Do this when your engagement with the client is strong enough to move forward. You need to strike the right balance between not having a focus at all (which leads to conversations that go nowhere) and being too rigid about focusing (which damages the relationship). * **Simple focusing**: You both already know what the focus of the conversation is. * **Multiple options to consider**: You’re not sure which option is the most important. * **The focus is unclear**: You don’t know what to work on. * **Directional not directive**: Motivational interviewing honors the client’s autonomy and self-determination. “Directional” means that you know the direction you want to move in. In contrast, “directive” is about you telling the other person what they need to do. Both client and therapist need to bring their expertise and blend it together. * **Agenda mapping**: **Lay out the choices. Elicit from them what they think is important. Be clear about what you think is important. Make a joint decision about what to focus on.** * Often, the focus might change during the conversation. Be mindful of how the topic of conversation is shifting. * Don’t hop between topics too quickly. * **When agendas conflict**: The interviewer and the client may have different goals. Do you have an aspiration for them? Are you comfortable with their aspirations? Are you comfortable working with this person towards these goals? **The client’s best interests are the reason why we’re here.** * **Ethical boundaries**: Mindset of compassion. Your primary focus is the well-being of the other person. If you’re uncertain, ask the person and be open about what you’d like for them, and listen to what they’d like. * **Focusing established before the session**: The focus may be established e.g. as part of the sign-up for the session. At the start of the session, ask them to fill you in a little bit. ## 4. Evoking * **Summary:** * Evoking: In Week 4 we explored the Evoking process, which in a way is the heart of MI and its most unique process. **Evoking calls forth the client’s own motivations for and ideas about change.** * First, we discussed how to **recognize change talk when you hear it**. We described **four kinds of preparatory change talk (DARN: Desire, Ability, Reasons, and Need) and three types of mobilizing change talk (CATs: Commitment, Activation, and Taking steps).** When you hear change talk, remember it as something important. * **Change Talk**: Change talk occurs naturally, but you don’t need to just wait for it to happen. **You can evoke it, arranging conversations so that your clients are more likely to express change talk.** It matters what you ask, and one Evoking approach is to ask open questions the answer to which is change talk. Other evoking strategies include using the importance ruler, querying extremes, looking forward or back, and exploring values. Basically, **you are thinking one step ahead: “If I say this, then what is the client likely to say next?”** * There are also particular **ways to respond to change talk when you hear it.** **The EARS responses are asking for Elaboration or an example, Affirming, Reflecting, and gathering change talk into bouquet Summaries.** Change talk often occurs intertwined with sustain talk, and it matters what you reflect. It is often tempting to focus on negativity, but in MI **you respond preferentially to change talk.** * **Evoking**: **Help the person move themselves towards change; to talk themselves into change.** * **The client has within them ideas and motivations for change that you want to draw out of them.** MI assumes an inherent drive towards flourishing. * Pay particular attention to what clients are saying, and to the **balance between sustain talk and change talk**. * **With a focus in place**, **evoking is about the question: “Why do you want to go there? Why do you want to make that change?”. ** * You help them hear themselves make the arguments for change. Motivation for change is already in them, and the interviewers job is to evoke that from them. * **What makes MI unique**: * **Paying particular attention to the client’s language**, and reflecting particular kinds of things. The therapist would emphasise change talk over sustain talk. * Also, there’s a lot of emphasis on the relationship. It’s a mechanism of change in and of itself. * **Language and movement**: * Ambivalence is a core part of the human experience, and **change talk** and **sustain talk** are simply the expression of this ambivalence. It’s normal for a person to want to change and not want to change at the same time. * **The job of an MI interviewer is to strengthen change talk and soften sustain talk. Move the balance in the direction of greater frequency and strength of change talk.** Give preferential attention to change talk. It’s normal for sustain talk to come up even in the later parts of the interaction. * **Change talk**: * The art of MI is to develop an ear for the various **kinds and strengths of change talk** — from “might”, “should”, to “will definitely do”. * You **listen for the relative proportion** of change talk relative to sustain talk. * Often they give you the seed of change talk, and your job is to offer something like a reflection or a question to let it grow. Hear the potential for change talk under the surface. * Tune your ear to hear change talk when it happens. **Anything that moves a person in the direction of change is change talk.** * **In order to know whether what you’re hearing is change talk, you need to know what your focus/goal is.** * Until you have a clear focus, it’s not time for evoking yet, because evoking is about eliciting change talk in the direction of the goal. * **Research suggests that change talk predicts actual change.** * **Preparatory change talk**: Things that people are saying when they are considering change. These things are moving people towards **considering change** more seriously. They are summarised with the acronym “**DARN**”: * **D**esire: **Why you want to make the change**. “I want to”, “I wish I could”. * **A**bility: **How you could do it**. “I can”, “I could”, “I’m able to”. * **R**easons: **A good reason for making the change**. “If I don’t change, then this happens”. * **N**eed: **How important it is and why; urgency**. “I’ve got to do something”, “I have to do this”, “I must”. * **Mobilizing change talk**: As people **get closer to making a change**, their language shifts. It’s more like a downhill slope. The acronym “**CATS**” captures the different kinds: * **C**ommitment: **What you intend to do**; decision, promise, “I will”, “I’m going to”. * **A**ctivation: **What you are ready or willing to do**; close to a promise, “I’m willing”, “I’ll consider”, “I’ll try”. * **T**aking **S**teps: **What you have already done**; actually taking some steps towards change. * **We learn what we believe by hearing ourselves talk**. We can talk ourselves into change or no change depending on how we’re arguing. **Change talk that really works when it arises spontaneously and organically in the conversation, not when someone makes you say it.** * **Sustain talk**: **Talk that favours carrying on the way things have been before.** DARN and CATS also appear here, but in the opposite/negative way. For instance: * D: “I don’t want to quit smoking” * A: “I can’t quit smoking” * R: “I feel fine” * N: “I don’t need to quit” * **Recognizing change talk**: Metaphor of the “MI hill”. “Preparatory change talk” can feel a bit like hiking up a hill, and it’s associated with DARN. When you begin to hear “mobilizing change talk”, it feels like going downhill, and it’s associated with CATS. * **Evoking change talk**: Sample strategies (see below) are open questions, the importance ruler, querying extremes. * **The common pattern when people are thinking on their own is to come up with a reason for change, and then come up with a reason against change, and then stop because it’s uncomfortable.** * **Your job is to help them stay in change talk and tell you all their motivations for change.** **Stand alongside them and encourage them, but don’t push them.** You’re just sitting next to an individual who’s telling you what’s important to them. **You don’t need to be clever. You need to be uncluttered and stay curious. “Sit on your hands” and don’t get in the way.** * **Open questions**: **Ask a question, the answer to which is change talk. You can use DARN to come up with questions. ** * Desire: “How would you like your life to be different?” * Ability: “If you did decide to make this change, how would you go about it?” * Reasons: “What would you say are the 3 best reasons to make this change?” * Need: “In what way is this important to you?” * **Importance ruler**: * “On a scale from 1-10, how important is it for you to make this change? 1 is not at all important, 10 is this is the most important thing in my life right now.” * They respond: “X”. * “And why did you give yourself an X, and not an X-2 or X-4 (give a lower number)?” * They answer with change talk. They verbalise what matters to them. * **Querying extremes**: Think about extremes. Seems similar to “Heaven and Hell”. * “If you do make this change, what might be the best thing that would happen?” * “If you don’t change anything, what’s the worst thing that might happen?” * **Looking forward & looking back**: * Go back to a time when things were better, and ask about that. * Look forward and ask them how they’d like their life to be like a year from now. * **Exploring values**: Explore what really matters to them. Look at that in relation to the change that’s being considered. Consider if the change would help them move towards what matters most to them. * The values card sort: A deck of cards with different values on them. Let the person sort the deck in order of importance to them. * **Reframing & lending change talk**: * Reframing: Invite the person to consider a different, usually positive meaning. Don’t impose it, but suggest it, almost in passing. * Lending. Use the “extension of the paragraph” reflection to suggest some change talk that they can say yes to. Offer something they might endorse, but they haven’t quite said yet. * **Thinking one step ahead**: **If you say this, what’s the client likely going to say next?** **Say something where you expect the next response to be change talk.** For each of your possible next actions, what do you think the client would be likely to say next? Is it more likely to be change talk or sustain talk? * **Responding to change talk**: What do you say when someone is giving you change talk? There are four ways, where OARS become **EARS**: * **E**xample or **E**laborate: “Give me an example of how you think this would help?” or “In what way would this be helpful?” * **A**ffirmations: “That sounds like a good idea.” * **R**eflections: Offer a complex reflection back and invite more change talk * **S**ummaries: “Three reasons you’ve told me so far as to why it would be good to make a change is that … What else?” * **Snatching change talk from the jaws of ambivalence**: Often, clients will give you several change talk and sustain talk statements. It’s seeing the little piece of change talk and responding to it rather than getting hooked by the negative. ## 5. Putting MI Into Practice * **Summary:** * In motivational interviewing you listen for and evoke change talk, which clients hear themselves say. You respond to change talk in ways (EARS) that are likely to reinforce it and evoke more, and then summarize the change talk you have heard. In this way, clients hear their own motivations for change voiced several times. * **Importance and confidence are different motivational issues, and it can be useful to consider which of these (or both) need strengthening.** MI can be used to enhance both importance and confidence. * Sustain talk is just the opposite side of change talk. The very same forms of speech – DARN CATs – can be spoken in defense of either change or the status quo. Sustain talk is normal and just represents one side of ambivalence. Discord, on the other hand, reflects dissonance in the working alliance, and often contains the word “you.” If unaddressed, both sustain talk and discord predict lack of change. In MI there are specific ways to respond to and “soften” these client responses so that they do not deter progress toward positive change. * **Using summaries to collect change talk**: * **Pull together in one bouquet the change talk “flowers” that the person voiced during the interview. Check with the person whether that’s how they see it as well. Then ask them what they think they’ll do. ** * A summary like this can create momentum by collecting the client’s own motivations for change. * **What to put into a summary**: * Don’t just focus on feelings and emotions – those are often unpleasant ones, and it tends to make people feel down even more rather than motivate them to change. * It is not necessary or even a good idea to offer a balance of change talk and sustain talk in your summary. **To encourage change, simply focus on the change talk they offered.** * Avoid a “prosecuting attorney” summary whereby you confront the person with the evidence that they “need to change”. This will make them defensive. * **Importance and confidence/self-efficacy**: * **Importance is how much motivation the person has to make a change.** * **Confidence is their belief about their ability to make the change.** * **People are unwilling to think that something is important if they believe that they can’t do it.** * Confidence language: The A in DARN – ability. * Questions: * 1. “**How important is it to you to consider changing this?**” – maybe use the importance ruler, 0-10 * 2. “**If you were to decide to make this change, how confident do you feel about succeeding?**” – maybe use the confidence ruler, 0-10 * “Why did you give yourself an X and not an X-2?” * “What would it take for you to get from an X to an X+2?” * **Evoking confidence**: * **Characteristics of successful changers**: A structured exercise that looks at the characteristics of the person that they might bring into the change process. * **Focus on strengths**, then reflect back the ability language that they offer: “What strengths do you have that you think might help you accomplish this change?” * **Ask about past successes**: What are some challenges they faced that they didn’t know they could be successful at at the time, but they prevailed. “What challenge have you faced in your life, and you didn’t know whether you’d be able to do it or not, but you ended up being successful.” * **Personal values card sort**: A structured exercise that brings the person’s deepest values forward into the conversation. Explore those values in greater detail and how those values increase the person’s importance for making a difficult change. * **When someone is lacking in confidence**: * Focus on the engagement process. * Examine what they have learned from past failure experiences. * Examine past successes. * Look for good qualities and strengths and use affirmations to point those out. * 1. **Help them clarify the “why”**. Focus on what they value and what they really need right now. * 2. **Help them build the courage to make gradual changes in small steps**. What would a small and meaningful step be? How could they implement that? * **Resistance or discord?** * **Resistance**: Anything the person says that moves them away from change. Carries the implication that it’s a problem inside someone else that you have to deal with. * **Discord**: Resistance isn’t about sustain talk, but about something that lives in the interaction between the client and the interviewer. This is about dissonance and tension between the two people, where the client doesn’t feel comfortable with what happens in the conversation with the interviewer. * For example: “You’re not hearing me. You don’t understand.” * Resistance is not a client characteristic. It’s an interpersonal process. It takes two people to resist. * Resistance is a signal for the interviewer to try something else. Don’t do more of what you just did. * Discord can also be useful. It can sometimes bring energy into the discussion that you wouldn’t otherwise have. * **Responding to sustain talk and discord**: * Watch out for things the client says that trigger you and bring out the righting reflex in you. * **Don’t cuddle the sustain talk. Don’t ignore it either. Acknowledge it so you don’t damage your rapport with the client. Having done that, turn your attention away from sustain talk and towards change talk instead.** * Your attitude: Sustain talk is normal. It’s to be expected. * Avoid defensiveness when you encounter discord. Apologise, sidestep the argument, or point out how you misunderstood them. ## 6. The Planning Process * **Calling the CATS**: Invite the client to make CATS statements — commitment, activation, taking steps; = mobilizing change talk. * 1. **Prepare a summary of the change talk.** * 2. **Ask a** **key question**: **“So what do you think you’ll do?”** or **“What’s next?”** * Make it softer than “What are you going to do?” * **If the client is still ambivalent after the key question, continue with evoking – it’s not time yet for planning.** * **Planning**: **Move from the general (the desired change) to the specific (how to make the change).** * **You don’t need to end each session with a plan. If you force it, you risk losing the motivation that the client has already gathered. Instead, let them continue their process after the session on their own.** * **Offering information and advice**: MI is not incompatible with giving someone information and advice. You can offer advice while **honoring the client’s freedom to make their own choice**. The framework is **E.P.E.**: * **1. Elicit**: **First find out what they already know or would like to know.** * **2. Provide**: **Put information on the table without attachment. Broaden the space of options rather than narrowing it down.** * Keep these providing segments short, and elicit again soon to check what’s useful to them. * **3. Elicit**: **Ask them what sense they make of the information. “What do you think?”** * **Offering information and advice with permission**: * 1. If the person directly asks you: Consider whether it might be more appropriate to first elicit before providing advice. If you move to providing, offer a handful of possibilities and ask which ones sound appealing to them. * 2. If you ask for it: “I have a couple of ideas here, would it be okay if I shared those?” or “I have a concern here, would it be okay for me to share that with you?” * 3. You feel like you have to tell them something: Raise a concern, and flag that it might not be a concern for them. * **Responses and requests for advice**: * Reactance: Avoid giving advice when the client feels like their freedom is being threatened. * Offer advice, don’t impose it on them. * Pay attention to the client’s language (balance between change and sustain talk) and the strength of the relationship before giving advice. * **Evoking a change plan**: * This should be a genuine collaborative effort. When clients themselves put the plan together, it’s like making a deposit into a bank account. When you add items to the plan, it’s like taking money out of the bank account. You want a change plan that has a positive balance. * **The important thing is coming to an agreement about what happens next.** * **Sometimes it’s enough to just specify one or two next steps.** * “What’s the next thing you’ll do?” * “What’s the first step?” * **Raising concerns about a change plan**: * The change plan might be wildly optimistic. In that case, ask permission, then raise your concern. * The change plan might not be ambitious enough. * **Evaluating your practice**: An initial course will produce modest gains in most people’s ability to use MI. **What helps is being observed in your practice and getting feedback from experts.** * **Audio-tape your sessions and review them with deliberate practice. Pay attention to one of the indicators of success in MI as you’re listening. Keep score for how closely you’re hitting the mark.** * For instance, keep track of how much change talk you’re getting from the client, and how that changes over the course of the session. * There’s an [MI skill code](https://casaa.unm.edu/download/MITI4_2.pdf) of markers that you can listen for. * **Pay attention to where things are going wrong and are not looking like MI. First, stop doing the things that aren’t MI.** * **Learning community**: Have two people do a 10-minute live demo in front of the group. * Treasure hunt: Every observer looks for what the interviewer does well. * Affirmation round: Every observer shares one thing they appreciated about the interviewer’s work. * Suggestion round: 1-2 people share one thing the interviewer could do to increase their MI skills. * **Integrating MI into your practice**: * MI has four processes. You can select one of these processes depending on what your client is bringing forward. * **Use MI first, and then move forward into a more directional approach, like CBT.** * When you use another approach and you’re getting pushback and ambivalence from the client, it may be a good time to use MI for a while. * **What makes a good therapist**: * **Empathy**: The ability to put yourself in someone else’s shoes and to let them know that you can see things from their perspective. Hear, understand, reflect back. * **Authenticity**: Being truly present as yourself, not playing a role. Let MI become an expression of who you are. * **Expert knowledge**: Use what we know about how people change. * Conveying a sense of hope and self-efficacy. * Having a clear direction and a coherent way of movement.