Motivational Interviewing

Miller, W.R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: The Guilford Press.

Prochaska-DiCelemente Stages of Change Model (and therapist tasks):

1. Precontemplation — “Raise doubt—increase the client’s perception of risks and problems w/ current behavior”
2. Contemplation — “Tip the balance—evoke reasons to change, risks of not changing, strengthen the client’s self-efficacy for change of current behavior”
3. Determination — “Help the client to determine the best course of action to take in seeking change”
4. Action — “Help the client to take steps toward change”
5. Maintenance — “Help the client to identify and use strategies to prevent relapse”
6. Relapse — “Help the client to renew the processes of conemplation, determination, and action, without becoming stuck or demoralized because of relapse” (18)

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Eight strategies counselors can use to help motivate people to change, A-H:

• Giving ADVICE — A “wholly nondirective strategy can leave a client confused and floundering” (20). Sometimes clients need advice. Advice should “(1) clearly identify the problem or risk area, (2) explain why change is important, and (3) advocate specific change” (21).
• Removing BARRIERS — Some clients are willing to consider changing, but there are practical barriers in their way—e.g., “cost, transportation, child care, shyness, waiting time, or safety concern.” The counselor should help clients overcome these barriers (21).
• Providing CHOICE — People don’t like “to be told what to do” (22). Consequently, counselors who offer “clients a choice among alternative approaches may decrease resistance and dropount, and may improve both compliance and outcome” (23).
• Decreasing DESIRABILITY — The counselor must “identify the client’s positive incentives for continuing his or her present behavior.” The counselor then works “to increase the person’s awareness and salience of adverse consequences of the behavior” (24). One way to decrease the desirability of drinking is to discourage the client’s friends from enabling him (25).
• Practicing EMPATHY — Showing empathy means “understanding another’s meaning through the use of reflective listening.” Studies have shown that “an empathic therapist style is associated w/ low levels of client resistance and w/ greater long-term behavior change” (26).
• Providing FEEDBACK — “People sometimes fail to change b/c they do not receive sufficient feedback about their current situation...An important motivational task of the counslor, then, is to provide clear feedback about a client’s current situation and its consequences or risks” (26).
• Clarifying GOALS — “Helping people to set clear goals has been found found to facilitate change. It is important, however, for a person to see the goal as realistic and attainable. Otherwise little or no effort will be made to reach the goal, even if it is acknowledge to be important” (27).
• Active HELPING — This means “being actively and affirmatively interested in your client’s change process.” For example, if your client misses a meeting, you would want to show that you’re concerned and call to ask the client if everything is okay (27).

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Six ingredients that make brief counseling programs effectives, FRAMES:

• FEEDBACK: The client is “given feedback on his or her current status,” sometimes by taking assessments (32).
• RESPONSIBILITY: The counselor emphasizes “the client’s personal responsibility for change” by giving such messages as the following: “It’s up to you to decide what to do w/ this information. Nobody can decide for you, and no one can change your drinking if you don’t want to change. It’s your choice, and if change is going to happen, you’re the one who has to do it” (33).
• ADVICE: The counselor tells the client “to make a change in drinking. Sometimes such advice has been the prescription of a specific goal, such as total abstinence” (33).
• MENU: The counselor offers the client “a menu of alternative strategies for changing the problem behavior” (33).
• EMPATHY:
• SELF-EFFICACY: Self-efficacy refers to “a person’s belief in his or her ability to carry out or succeed with a specific task.” So the counselor here is trying to reinforce “the client’s self-efficacy, hope, or optimism” (34).

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Ambivalence — “I want to, but I don’t want to” change (36). Ambivalence is “normal, acceptable, and understandable” (38).

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“Motivational interviewing is a particular way to help people recognize and do something about their present or potential problems. It is particularly useful with people who are reluctant to change and ambivalent about changing it. It is intended to help resolve ambivalence and to get a person moving along the path to change. For some people, this is all they reall need. Once they are unstuck, no longer immobilized by conflicting motivations, they have the skills and resources they need in order to make a lasting change. All they need is a relatively brief motivational boost. For others, motivational interviewing is only a prelude to treatment (though an important one). It creates an openness to change, which paves the way for further important therapeutic work.

“In motivational interviewing, the counselor does not assume an authoritarian role. One avoids the message that ‘I’m the expert and I’m going to tell you how you need to run your life.’ Responsibility for change is left with the individual…

“The overall goal is to increase the client’s intrinsic motivation, so that change arises from within rather than being imposed from without. When this approach is done properly, it is the client who presents the arguments for change, rather than the therapy...In contrast to more aggressive styles, the counselor may at times appear relatively inactive. Yet the motivational interviewer proceeds with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments” (52).

CBT approaches teaching “the person how to change,” while MI builds “commitment (the why) to change” (54).

Five principles underlying MI:

1. Express Empathy — “Through skillful reflective listening, the therapist seeks to understand the client’s feelings and perspectives withotu judging, criticizing, or blaming. It is important to note here that acceptance is not the same thing as agreement or approval” (55-56).
2. Develop Discrepancy — The therapist wants to “create and amplify, in the client’s mind, a discrepancy b/t present behavior and broader goals” (56), or “a discrepancy b/t where one is and where one wants to be” (57)
3. Avoid Argumentation — The last thing the therapist wants to do is get into an argument in which the therapist “is arguing that the client has a problem and needs to change, while the client is defending an opposite viewpoint.” “Direct argumentation tends to evoke” resistance from the client (58).
4. Roll with Resistance — “Reluctance and ambivalence are not opposed, but are acknowledged by the therapist to be natural and understandable. The counselor does not impose new views or goals. Rather, the client is invited to consider new information and is offered new perspectives.” The therapist doesn’t give the client the answer; rather, the client is considered “a capable individual, with important insight and ideas for the solution of his or her own problems” (60).
5. Support Self-Efficacy — The therapist tries “to increase the client’s perceptions of his or her capability to cope with obstacles and to succeed in change” (61).

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Phase I: Building Motivation for Change

The question-answer trap. To avoid this, avoid asking more than three questions in a row. Instead, after asking a question, use reflective listening (66).

The first session. Provide “the client with a simple and brief structuring of the first session, and of counseling in general. A good restructuring statement can set the client’s mind at rest and get counseling off to a good start” (70-71). The therapist might want to include the amount of time available, an “explanation of your role and goals,” a “description of the client’s role,” a “mention of details that must be attended to,” an “open-ended question” (71).

Five early strategies:

1) Ask open-ended questions. You want the client to do most of the talking (71).

2) Listen reflectively.

3) “[A]ffirm and support your client during the counseling process” (77).

4) Summarize.

5) Elicit self-motivational statements. These are four self-motivational statements (a) problem recognition (when client recognizes there’s a problem), (b) expression of concern (when they’re worried about things), (c) intention to change (when they want to change), or (d) optimism about change (when they think they can change) (80-81). It’s important to encourage clients when they make self-motivational statements. The goal of the therapist is to elicit these statements. There are different ways to do this.

5a) Ask open-ended questions (what follows is quoted verbatim):

1. Problem Recognition
1. What things make you think that this is a problem?
2. What difficulties have you had in relation to your drug use?
3. In what ways do you think you or other people have been harmed by your drinking?
4. In what ways has this been a problem for you?
5. How has your use of tranquilizers stopped you from doing what you want to do?
2. Concern
1. What is there about your drinking that you or other people might see as reasons for concern?
2. What worries you about your drug use?  What can you imagine happening to you?
3. How do you feel about your gambling?
4. How much does that concern you?
5. In what ways does this concern you?
6. What do you think will happen if you don’t make a change?
3. Intention to change
1. The fact that you’re here indicate that at least a part of you thinks it’s time to do something. What are the reasons you see for making a change?
2. What makes you think that you may need to make a change?
3. If you were 100% successful and things worked out exactly as you would like, what would be different?
4. What things make you think that you should keep on drinking the way you have been?  And what about the other side? What makes you think that it’s time for a change?
5. What are you thinking about your gambling at this point?
6. What would be the advantages of making a change?
7. I can see that you’re feeling stuck at the moment. What’s going to have to change?
4. Optimism
1. What makes you think that if you did decide to make a change, you could do it?
2. What encourages you that you can change of you want to?
3. What do you think would work for you, if you decided to change? (82)

5b) The decisional balance — ask about both the positives and negatives of their behavior (83).

5c) Elaboration — “Once a motivational topic has been raised, it is useful to ask the client to elaborate,” e.g., “In what way is that a concern for you?” “Give me an example” (83).

5d) Using extremes — Ask them “to imagine worst consequences,” e.g., “What concerns you the most?” “What are your worst fears about what might happen if you don’t make a change?” “What do you suppose are the worst things that might happen if you keep on the way you’ve been going?” (84).

5e) Looking back — Ask them to “remember times before the problem emerged, and to compare these with the present situation” (84).

5f) Looking forward — Help them to “envision a changed future,” e.g., “If you do decide to make a change, what are your hopes for the future?” (85)

5g) Exploring goals — Ask client what is most important in their life and then “discover ways in which the problem behavior is inconsistent with or undermines important values and goals for the client” (85).

5h) Paradox — The therapist takes the “no-problem” side, intending to provoke the client into take the other side, e.g., “You’ve come all the way down here to talk to me about this, but you haven’t convinced me yet that you’ve got a real concern. Is that all?” “Let me tell you something that concerns me. A program like this one requires a lot of motivation and effort. We don’t really want to start working with somebody until they’re sure they need to change, and frankly, I’m not sure about you. As I listen to you, I’m not convinced you’re motivated enough.” If the client responds with a self-motivational statement, this strategy is working (86).

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Resistance

Research shows “that the extent to which clients ‘resist’ is powerfully determined by therapist style. This finding is not due just to differences b/t therapists. Dramatic differences in client resistance have been shown when the same therapists take different approaches with clients, or even switch styles within the same session” (100).

This “means that you can judge your success in counseling, in part, from the extent to which your clients show resistance — the less the better, In this way, your clients will give you feedback about the effectiveness of your own motivational interviewing. This is a great advantage in learning how to adapt this approach in your own work. If you get resistance, shift strategies” (101).

Recognizing Resistance. “From the perspective of the Prochaska-DiCelemente model, [resistance] may mean that the therapist is using strategies that are inappropriate at the client’s present stage of change” (101).

Four Categories of Client Resistance Behavior (copied verbatim)

1. Arguing. The client contests the accuracy, expertise, or integrity of the therapist.
1. Challenging
2. Discounting.
3. Hostility.
2. Interrupting. The client breaks in and interrupts the therapist in a defensive manner.
1. Talking over.
2. Cutting off.
3. Denying. The client expresses an unwillingness to recognize problems, cooperate, accept responsibility, or take advice.
1. Blaming.
2. Disagreeing.
3. Excusing.
4. Claiming impunity.
5. Minimizing.
6. Pessimism.
7. Reluctance.
8. Unwillingness to change.
4. Ignoring. The client shows evidence of not following or ignoring the therapist.
1. Inattention.
2. Nonanswer.
3. No response.
4. Sidetracking. (103)

Strategies for Handling Resistance.

1. Simple reflection — don’t resist, simply acknowledge the client’s “disagreement, emotion, or perception,” use a “reflective-listening statement” (102).
2. Amplified reflection — to state the what the client has said “in an even more extreme fashion than the client has done. If successful, this will encourage the client to back off a bit, and will elicit the other side of the client’s ambivalence.” Be careful not to be sarcastic. E.g., C: “I can hold my liquor just fine. I’m still standing when everybody else is under the table.” T: “So you really have nothing to worry about; alcohol can’t hurt you at all” (104).
3. Double-sided reflection — “to acknowledge what the client has said, and add to it the other side of the client’s ambivalence.” E.g., C: “I’m not an alcoholic. It’s just that Pat used to be married to an alcoholic, and thinks that anybody who overdoes it now and then has a problem.” T: “You can see that sometimes you have trouble with drinking too much, but it seems to you that Pat is making too much of it” (105).
4. Shifting focus — “shift the client’s attention away from what seems to be a stumbling blocking standing in the way of progress” (105). E.g., C: “OK, maybe I’ve got some problems with drinking, but I’m not an alcoholic.” T: “I don’t think that’s the issue at all, and I don’t want you worrying about it. It’s not important to me whether or not you want to think of yourself as an alcoholic. I am worried, though, as you are, about some of the things that seem to be happening in your life. Tell me a little more about…” (106).
5. Agreement with a twist — C: “Why are you and my wife so stuck on my drinking? What about all her problems? You’d drink, too, if your family were nagging you all the time.” T: “You’ve got a good point there, and that’s important. There is a bigger picture here, and maybe I haven’t been paying enough attention to that. It’s not as simple as one person’s drinking. I agree with you that we shouldn’t be trying to place blame here. Drinking problems like these do involve the whole family. I think you’re absolutely right” (106).
6. Emphasizing personal choice and control — assure the client “that in the end, it is the client who determines what happens.” E.g., T: “What you do with this information is completely up to you,” “If you decide that you don’t want to change, then you won’t. If you want to change, you can. It’s your choice” (107).
7. Reframing
8. Therapeutic Paradox