Motivational Interviewing

Motivational interviewing encourages people to talk about their need for change and their own reasons for wanting to change.

• Evokes a conversation about change and commitment. 
• Reflects back the person’s thoughts so that the person can hear their reasons and motivations expressed back to them. 
• Generally it’s short-term counseling that requires just one or two sessions, but it can also be included as an intervention along with other, longer-term therapies.

Foundations:

• “Person-centered” approach to counseling and therapy, as a method to help people commit to the difficult process of change.
• Goal 1: Increase the person’s motivation.
• Goal 2: For the person to make the commitment to change.
• Hearing themselves express a commitment out loud has been shown to help improve a perons’s ability to actually make those changes.
• Interviewer LISTENS more than actually interviewing.
• Motivational interviewing is often combined or followed up with other interventions, such as cognitive therapy, support groups.

A Good Interviewer:

• Must be empathetic and supportive, as well as a good listener. 
• Usually better to be a health professional
• Interviewing is a skill that improves with time
• The person must feel comfortable with the interviewer

Interviewer Self Evaluation:

• Do I listen more than I talk? Or am I talking more than I listen?
• Do I keep myself sensitive and open to this person’s issues, whatever they may be? Or am I talking about what I think the problem is?
• Do I invite this person to talk about and explore his/her own ideas for change? Or am I jumping to conclusions and possible solutions?
• Do I encourage this person to talk about his/her reasons for not changing? Or am I forcing him/her to talk only about change?
• Do I ask permission to give my feedback? Or am I presuming that my ideas are what he/she really needs to hear?
• Do I reassure this person that ambivalence to change is normal? Or am I telling him/her to take action and push ahead for a solution?
• Do I help this person identify successes and challenges from his/her past and relate them to present change efforts? Or am I encouraging him/her to ignore or get stuck on old stories?
• o I seek to understand this person? Or am I spending a lot of time trying to convince him/her to understand me and my ideas?
• Do I summarize for this person what I am hearing? Or am I just summarizing what I think?
• Do I value this person’s opinion more than my own? Or am I giving more value to my viewpoint?
• Do I remind myself that this person is capable of making his/her own choices? Or am I assuming that he/she is not capable of making good choices?

A Common Hurdle People Need to Work Through

Ambivalence

• It is when people may want to stop overeating, but at the same time, they do not want to. 
• A natural state, and is completely normal, regardless of the client’s state of readiness
• It’s important to understand and accept a person’s ambivalence as it is often the central problem–and lack of motivation can be a manifestation of this ambivalence 
  • Caution not to interpret ambivalence as resistance or denial, this leads to friction 

Examples of possible conflicts that can cause ambivalence

Stage Specific Conflicts That Can Lead to Ambivalence		Interviewers Roll in the stage
Stage	Conflict
Precontemplation When the person does not recognize a problem, or is not willing to change	I don’t see how my eating use warrants concern, but I hope that by agreeing to talk about it, my wife will feel reassured.	Build report and build a relationship. Inform and encourage.
Contemplation The person is evaluating reasons for or against change	I can picture how changing what I eat would improve my self-esteem, but I can’t imagine never eating that food again.	Explore and resolve ambivalence
Preparation The person is planning for change.	I’m feeling good about setting a quit date, but I’m wondering if I have the courage to follow through.	Negotiate a plan. Facilitate decision making.
Action The person is making identified changes.	Eating healthfully for the past 3 weeks really makes me feel good, but part of me wants to celebrate by eating hyperpalatable hypercaloric foods..	Support implementation of the plan. Support Self-efficacy.
Maintenance The person is working on sustained change.	These recent months of abstinence have made me feel that I’m progressing toward recovery, but I’m still wondering whether abstinence is really necessary.	Help maintain change. Help avoid relapse.
*Table Adapted from “Enhancing Motivation for Change in Substance Abuse Treatment,” see Sources for full reference.		Modified from  UI SBIRT slides

Cultivating a good relationship, what not to do:

• Ordering or directing.
  • This can be a simple phrase or tone of voice. Creates a position of power, unleveling the field

• Warning or threatening.
  • Discussing impending negative consequences if the advice or direction is not followed.

• Giving advice, making suggestions, or providing solutions prematurely or when unsolicited.
  • Recommendations often begin with phrases such as, “What I would do is….”

• Persuading with logic, arguing, or lecturing.
  • The assumption of these messages is that the client has not reasoned through the problem adequately and needs help to do so.

• Moralizing, preaching, or telling clients their duty. 
  • Using words such as “should” or “ought” to convey moral instructions.

• Judging, criticizing, disagreeing, or blaming.
  • Even simple disagreement may be interpreted as critical.

• Agreeing, approving, or praising.
  • Praise or approval also can be an obstacle
  • if the message sanctions or implies agreement with whatever the client has said. 

• • Unsolicited approval can interrupt the communication process and can imply an uneven relationship between the speaker and the listener. 
  • Reflective listening does not require agreement.

• Shaming, ridiculing, labeling, or name-calling.

• • express overt disapproval and intent to correct a specific behavior or attitude.

• Interpreting or analyzing. 
  • Interviewers are easily tempted to impose their own interpretations on another person’s statement and to find some hidden, analytical meaning. 
  • Interpretive statements might imply that the interviewer knows what the client’s real problem is. 

• Reassuring, sympathizing, or consoling. 
  • Interviewers often want to make the client feel better by offering consolation. 
  • Such reassurance can interrupt the flow of communication and interfere with careful listening.

• Questioning or probing.
  • Interviewers often mistake questioning for good listening. 
  • Although the clinician may ask questions to learn more about the person, the underlying message is that the interviewer might find the right answer to all the client’s problems if enough questions are asked. 
  • In fact, intensive questioning can interfere with the spontaneous flow of communication and divert it in directions of interest to the clinician rather than the client.

• Withdrawing, distracting, humoring, or changing the subject. 
  • Although humor may represent an attempt to take the interviewer’s mind off emotional subjects or threatening problems, it also can be a distraction that diverts communication and implies that the person’s statements are unimportant.

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.

Please note, this post is just a snapshot into what is known as “motivational interviewing.” It is meant to shine a light on a form of person to person interaction that can be learned. All information put for is for educational purposes only. We recommend pursuing further education on this subject before trying to implement such a program on a patient or client. Content is also NOT meant to act as therapy.

Sources:

Hettema J1, et. al. Motivational interviewing.Annu Rev Clin Psychol. 2005;1:91-111. 

https://www.integration.samhsa.gov/clinical-practice/motivational-interviewing

MI Reminder Card (Am I Doing This Right?).Ric Kruszynski, Paul M. Kubek, Deborah Myers, and Jeremy Evenden Publication Year: 2012. Cleveland. Center for Evidence-Based Practices at Case Western Reserve University

https://www.ncbi.nlm.nih.gov/books/NBK64964/

Motivational Interviewing as a Counseling Style; Treatment Improvement Protocol (TIP) Series, No. 35. Center for Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999.

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People To Change Addictive Behavior. New York: Guilford Press, 1991

Kanfer, F.H., and Schefft, B.K. Guiding the Process of Therapeutic Change. Champaign, IL: Research Press, 1988

Van Bilsen, H.P. Motivational interviewing: perspectives from the Netherlands with particular emphasis on heroin-dependent clients. 

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People To Change Addictive Behavior. New York: Guilford Press, 1991. pp. 214-235.

Alcoholics Anonymous. Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered From Alcoholism, 3rd ed. New York: Alcoholics Anonymous World Services, 1976.