Five Principles to MI

1. Be empathetic
2. Develop discrepancies
3. Avoid argument
4. Roll with resistance
5. Support self-efficacy

Be Empathetic

Empathetic characteristics

• Communicates respect for and acceptance of clients and their feelings
• Encourages a nonjudgmental, collaborative relationship
• Allows you to be a supportive and knowledgeable consultant
• Sincerely compliments rather than denigrates
• Listens rather than tells
• Gently persuades, with the understanding that the decision to change is the client's
• Provides support throughout the recovery process
• Interviewers attitude should be one of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected.

“...should not be confused with the meaning of empathy as identification with the client or the sharing of common past experiences. In fact, a recent personal history of the same problem area...may compromise a counselor's ability to provide the critical conditions of change (Miller).”

Develop Discrepancies

• Help focus your client's attention on how current behavior differs from ideal or desired behavior.
  • Although helping a person perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.
• Explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current substance use patterns. 
• Listen closely to values and connections to community, family, and church.
• "Columbo approach"
  • Good for people who want to be in control
  • The interviewer expresses understanding and continuously seeks clarification of the client's problems but appears unable to perceive any solution.
    • “A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution…” (Van) 
• It is useful to understand not only what an individual values but also what the community values.
  • Ex: overeating might conflict with the peron’s personal identity and values; it might conflict with the values of the larger community; it might conflict with spiritual or religious beliefs; or it might conflict with the values of the client's family members. Thus, discrepancy can be made clear by contrasting overeating
  •  behavior with the importance the clients ascribe to their relationships with family, religious groups, and the community.
• The person should present the arguments for change, not the interviewer

Avoid Arguments

• trying to convince a person that a problem exists or that change is needed could precipitate even more resistance.
  • If you try to prove a point, the client predictably takes the opposite side
• When it is the person, not the interviewer, who voices arguments for change, progress can be made.
• A common area of argument is the person’s unwillingness to accept being labeled obese, or overweight.
  • “[T]here is no particular reason why the therapist should badger clients to accept a label, or exert great persuasive effort in this direction. Accusing clients of being in denial or resistant or addicted is more likely to increase their resistance than to instill motivation for change. We advocate starting with clients wherever they are, and altering their self-perceptions, not by arguing about labels, but through substantially more effective means.” (Miller)
  • The general principle here is labels should not be imposed but should be a personal decision of the individual. From an article published in 1976 (AA), which still seems very important in 2019. 

Roll With Resistance

• Resistance is important as it is associated with poor treatment outcomes and lack of involvement in the therapeutic process.
• Often misunderstood as defiance
  • A more constructively it can be viewed as a sign the person views the situation differently. The interviewer needs to better understand the person’s viewpoint.
• Signals likely need to change directions or listen more carefully
• Ways to handle it
  • Simple Reflection: a simplest approach to responding to resistance is with nonresistance, by repeating the client's statement in a neutral form
    • Person: I don’t plan to try low carb any time soon
    • Interviewer: You don’t think trying to stay away from carbs will work for you right now.
  • Amplified Reflection: state it in a more extreme way but without sarcasm.
    • Resistance: I don’t know why my husband is worried about my weight, I am the same size as all my friends.
    • Interviewer: So your husband is worried needlessly.
  • Double-sided Reflection: acknowledging what the person has said but then also stating contrary things she has said in the past. 
    • This requires the use of information that the person has offered previously, although perhaps not in the same session. (the benefit of having a one on one relationship)
      • Person: I know you want me to give up cookies, but I won’t do that! 
      • Interviewer: You have seen problems with the way you eat, but at this time you aren’t willing to think about quitting cookies completely.
  • Shifting Focus
    • defuse resistance by helping the client shift focus away from obstacles and barriers. 
    • This offers an opportunity to affirm your client's personal choice regarding the conduct of his own life.
      • Person: I can’t not eat when all my friends are eating.
      • Interviewer: We’re still exploring concerns about being a physician who is also overweight. We’re not yet ready to explore how to eat socially. 
  • Agreement With A Twist
    • Agree with the person, but with a slight twist to help move on.
      • Person: Why are you and my husband so stuck on my eating? What about all his problems? You’d eat too if your family was nagging you all the time.
      • Interviewer: You have a good point there. 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 eating. I agree with you that we shouldn't be trying to place blame here. Overeating problems like these do involve the whole family.
  • Reframing
    • when a person denies personal problems
      • "acknowledges the validity of the client's raw observations, but offers a new meaning...for them" (Miller)
        • Person: My husband is always nagging me about my eating, it really bugs me.
        • Interviewer: It sounds like he is worried about you, but he isn’t able to express his worry in a productive way. Maybe we can help him learn how to tell you he loves you in a more acceptable way. 

Support Self-Efficacy

• • Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change.
  • The person’s perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in ambivalence
  • The interviewer must recognize the person’s strengths
  • The person must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward.
  • Examples
    • Discussing treatment or change options that might still be attractive to the person is usually helpful, even though they may have dropped out of the past program, or regained the weight
    • Discussion other people in the similar situation successes, showing it can be done. The “if they can do it, I can do it” mentality.
    • Discuss the biology of adiposity, educate the person to help empower them. This may alleviate shame and guilt, and instill hope.
    • Discuss all the different nutritional methods that can lead to weight loss. Alternative approaches can be used whenever needed.