Motivational interviewing

Question 1

What is the difference between a directing, following and guiding style?

Answer 1

in a directing style, a helper:
- provides information, instruction and advice
- Tells people what to do and how to proceed
- the client: Obeys, complies and
adheres
- example: a doctor telling a patient how to take
medication

in a following style, a helper:
- listens, understands and refrains from inserting their
own material
- Trust in the clients own wisdom
- The client: takes the lead, explores and discovers
- example: a Rogerian therapist
-“I trust your own wisdom, will stay with you, and will let
you work this out in your own way.”

in a guiding style, a helper:
- combines both directing and following.
- listens intently and provides advice where needed.
- example: a tour guide, that neither orders the client
around or let them wander aimlessly, listening to
understand the clients needs and to where the client
wants to go and also providing useful information
about the journey

Question 2

What is the righting reflex?

Answer 2

The desire to fix what seems wrong with people and to set them promptly on a better course, relying in particular on directive style by telling people what they should do and how they should do it

The righting reflex involves the belief that you must convince or persuade the person to do the right thing.

People tend to feel bad in response to the righting reflex, and causing people to feel bad doesn’t help them to change.

Question 3

What is ambivalence?

Answer 3

It is natural part of the change process where people simultaniously want and don’t want something or want two things that are incompatible.

“Yes, but . . . ” is the cadence of ambivalence.

Question 4

What is “change talk”?

Answer 4

Statements, made by a person, about wanting to make a change. Also known as “self-motivational statements”

Question 5

What is “sustain talk”?

Answer 5

Statements or arguments, made by a person, for not changing or for maintaining the status quo

Question 6

How can we recognize ambivalence?

Answer 6

Both Sustain and Change talk occur naturally, often within the same sentence: “I need to do something about my weight [change talk] but I’ve tried about everything and it never lasts [sustain talk]. I mean, I know I need to lose weight for my health [change talk] but I just love to eat [sustain talk].” “Yes, but . . . ” is the cadence of ambivalence.

Question 7

Why do people remain stuck in ambivalence, even though it is an uncomfortable place to be in?

Answer 7

Because they are vacillating between two choices, two paths, or two relationships. When they take a step in one direction, the other starts looking better. The closer they get to one alternative, the more its disadvantages become apparent while nostalgia for the other beckons.

A common pattern is to think of a reason for changing, then think of a reason not to change, then stop thinking about it.

Question 8

What is the way out of ambivelance?

Answer 8

The way out is to choose a direction and to follow it, and to keep on following it.

Question 9

Why do helpers, with a righting reflex or a directive helping style often fail to help ambivelant clients?

Answer 9

Because both arguments for and against allready resides within the person, so when the helper takes up and emphasize only one side of the argument, the side for change, the client predictably takes up and defends the opposite side of the argument, with “yes, but…”, or “but..”

Question 10

Why are ambivelant clients often labled as “resistant”?

Answer 10

because on the serface they seem to resist or oppose change, but rahter than being a personallity defect, resistance is a product of a dysfunctional coaching relationship or approach that is too directive.

Question 11

According to the theory of self-perception, “people learn about their own attitudes and beliefs in the same way that others learn them: by hearing themselves talk”, why is this important to remember when working with ambivalent clients?

Answer 11

Because being too directive, arguing for one side of an issue, will move the client’s balance of opinion in the opposite direction, causing them to verbalize the opposite side of the issue, and most people tend to believe themselves and trust their own opinions more than those of others, resulting in a reinforcement of an oppositional pattern.

Ideally, the client should be voicing the reasons for change

Question 12

What is motivational interviewing?

Answer 12

Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.

MI is designed to find a constructive way through the challenges that often arise when a helper ventures into someone else’s motivation for change.

Question 13

The spirit of MI

Answer 13

Partnership, Acceptance, compassion, Evocation

Question 14

Partnership

Answer 14

MI is not something done by an expert to a passive recipient, a teacher to a pupil, a master to a disciple. In fact it is not done “to” or “on” someone at all. MI is done “for” and “with” a person. It is an active collaboration between experts.

Partnership is interest and support rather than persuasion or argument.

Question 15

Why is Partnership important

Answer 15

Why is this important? One simple reason is that when the goal is for another person to change, the counselor can’t do it alone. The client has vital expertise that is complementary to your own. Activation of that expertise is a key condition for change to occur

Question 16

Metaphor for partnership?

Answer 16

MI is like dancing rather than wrestling. One moves with rather than against the person. It is not a process of overpowering and pinning an adversary. A good MI conversation looks as smooth as a ballroom waltz. Someone is still leading in the dance, and skillful guiding is definitely part of the art of MI, without tripping or stepping on toes. Without partnership there is no dance.

Question 17

What is the expert trap?

Answer 17

A pitfall where communicating that, based on your professional expertise, you have the answer to the person’s dilemma.

It is the assumption that you are supposed to have and provide all the right answers.

The expert trap is fertile ground for the righting reflex to spring up, as it resutls in pressure to dispense one’s expertise

Question 18

Four elements of Acceptance?

Answer 18

Absolute worth, Autonomy, Accurate Empathy, Affirmation and Evocation

One honors each person’s absolute worth and potential as a human being, recognizes and supports the person’s irrevocable autonomy to choose his or her own way, seeks through accurate empathy to understand the other’s perspective, and affirms the person’s strengths and efforts.

Question 19

Absolute worth

Answer 19

unconditional possitive regard: Respecting and Regarding the other as having intrinsic worth and as trust worthy.

Respect here means: the concern that the other person should grow and unfold as he is. Respect is the absence of exploitation.

The opposite of this attitude is one of judgment, placing conditions on worth: “I will decide who deserves respect and who does not.”

Question 20

What does Aboslute worth not mean?

Answer 20

To accept a person in this sense does not mean that you necessarily approve of the person’s actions or acquiesce to the status quo.

Question 21

Why is acceptance a nessecary condition for change?

Answer 21

when people experience themselves as unacceptable they are immobilized. Their ability to change is diminished or blocked. When, on the other hand, people experience being accepted as they are, they are freed to change.

Question 22

Menshenbild

Answer 22

A view of human nature

Question 23

What is the humanistic menshenbild?

Answer 23

Human behaviour is fundamentally “positive, forward moving, constructive, realistic, and trustworthy”

That humans have a tendency towards self-actualization and when ciritcal therapeutic conditions are met, people will naturally change or grow in a positive direction, towards their telos (mature end state or purpose)

Question 24

Empathy

Answer 24

an active interest in and effort to understand the other’s internal perspective, to see the world through her or his eyes.

“to sense the client’s inner world of private personal meanings as if it were your own, but without ever losing the ‘as if’ quality”

Question 25

difference between Empathy and sympathy

Answer 25

empathy is an ability to understand another’s frame of reference and the conviction that it is worthwhile to do so.

Sympathy is a feeling of pity for or camaraderie with the person.

Question 26

Difference between Empathy and identification

Answer 26

empathy is an ability to understand another’s frame of reference and the conviction that it is worthwhile to do so.

identification: “I’ve been there and I know what you’re experiencing. Let me tell you my story.”

Question 27

The opposite of Empathy

Answer 27

The opposite of empathy is the imposition of one’s own perspective, perhaps with the assumption that the other’s views are irrelevant or misguided.

Question 28

Autonomy

Answer 28

A person’s irrevocable right and capacity of self-direction

Question 29

Autonomy support

Answer 29

Allowing people the freedom to be and choose

This involves letting go of the burden or idea that you have to “make” people change, It is relingquishing a power that you never had in the first place.

Question 30

The opposite of Autonomy support.

Answer 30

The opposite of autonomy support is the attempt to make people do things, to coerce and control.

Question 31

What happens when you offer autonomy support?

Answer 31

directly acknowledging a person’s freedom of choice typically diminishes defensiveness and can facilitate change.

Question 32

Affirmation

Answer 32

to seek and acknowledge the person’s strengths and efforts.

Question 33

The opposite of Affirmation

Answer 33

Its opposite is the search for what is wrong with people (which is so often the focus of “assessment”), and having identified what is wrong, to tell them how to fix it.

Miller, William R.; Rollnick, Stephen. Motivational Interviewing, Third Edition (Applications of Motivational Interviewing) (Kindle Locations 485-486). Guilford Publications. Kindle Edition.

Question 34

Compassion

Answer 34

Compasion is not just the removal of suffering. To be compassionate is to actively promote the other’s welfare, to give priority to the other’s needs.

Question 35

What is compassion not?

Answer 35

It is not a personal experience or feeling like sympathy.

Question 36

The deficit model

Answer 36

deficit model, that the person is lacking something that needs to be installed or corrected by professional expertise

The implicit message is “I have what you need, and I’m going to give it to you,” be it knowledge, insight, diagnosis, wisdom, reality, rationality, or coping skills.

Question 37

What is evocation and how is it different from the deficit model?

Answer 37

that people already have within them much of what is needed, and your task is to evoke it, to call it forth.

The implicit message is “You have what you need, and together we will find it.”

From this perspective it is particularly important to focus on and understand the person’s strengths and resources rather than probe for deficits

Question 38

How does the spirit of evocation fit with the conception of ambivalence?

Answer 38

People who are ambivalent about change already have both arguments within them— those favoring change and those supporting status quo. This means that most clients do already have pro-change voices on their internal committee, their own positive motivations for change. These are likely to be more persuasive than whatever arguments you might be able to provide. Your task, then, is to evoke and strengthen these change motivations that are already present.

Question 39

Stages

Answer 39

1. Engage
2. Focus
3. Evoke
4. Plan

Question 40

Engage

Answer 40

The process of establishing a mutually trusting and respectful helping relationship

Question 41

Disengagement Trap 1: The assessment trap

Answer 41

The structure of an assessment-intensive session is clear: the interviewer asks the questions and the client answers them. This quickly places the client in a passive and one-down role (Rogers, 1942). Furthermore, the usefulness of all this questioning is not necessarily apparent to the client, who already knows the information being conveyed. Rogers (1942) observed: The disadvantages of using tests at the outset of a series of therapeutic contacts are the same as the disadvantages of taking a complete case history. If the psychologist begins his work with a complete battery of tests, this fact carries with it the implication that he will provide the solutions to the client’s problems. . . . Such “solutions” are not genuine and do not deeply help the individual. (p. 250)

it sets the expectation of an active expert and a passive patient. It affords little opportunity for people to explore their own motivation and to offer change talk. The client’s part in this relationship is mostly limited to answering the interviewer’s questions.

Question 42

Disengagement trap 2: The expert Trap

Answer 42

Asking a run of questions not only communicates that “I’m in control here,” but it also sets up an implicit expectation that once you have collected enough information you will have the answer.

An “information-in– answer-out” expert role does not work so well, however, when what is needed is personal change, and it sets the stage for both of you to be disappointed. A prescription to “just do this” is seldom effective in itself, and the provider’s consequent frustration is that “I tell them and I tell them and I tell them, and still they don’t change!” Part of MI is knowing that you don’t have the answers for clients without their collaboration and expertise.

Question 43

Disengagement Trap 3: The premature Focus Trap

Answer 43

The basic problem here is focusing before engaging, trying to solve the problem before you have established a working collaboration and negotiated common goals. You want to talk about a particular problem, and the client is concerned about a different topic. This very situation has been one common reason for clinical interest in MI. Counselors often want to identify and home in on what they perceive to be the person’s “real” problem. The client, on the other hand, may have more pressing concerns, and may not share the importance placed by the counselor on this “problem.”

The trap here is to persist in trying to draw the person back to talk about your own conception of the problem without listening to the client’s broader concerns. A struggle may ensue regarding what should be discussed. Indeed, in the person’s mind, the counselor’s concern may be a relatively small part of the picture, and it may not be clear whether and how this is related to the person’s larger life issues. If the counselor presses too quickly to focus the discussion, discord results and the person may be put off, becoming defensive.

Starting with the person’s own concerns rather than those of the counselor will ensure that this does not happen. Very often, exploring those things that are of concern to the person will lead back to the topic that is of concern to the counselor, particularly when the areas of concern are related. In any event, spending time listening to the person’s concerns is useful both in understanding the person and in building rapport that is a basis for engagement and later exploration of other topics.

A women’s substance abuse treatment program in New Mexico illustrates this situation. The professional staff found that women who came to the program generally had many more pressing concerns than their use of alcohol and other drugs. They often had health care issues, parenting and child care problems, needed housing, and were traumatized by current or past physical and sexual abuse. These women had much to talk about, and if a counselor tried to home in on substance use too early in treatment, the woman was likely to drop out. If, on the other hand, the counselor listened to and addressed the woman’s immediate concerns, conversations invariably came around to the role of alcohol and other drugs in her life.

When encountering discord around premature focus, start where your clients’ own concerns are, listen to their stories, and get a broader understanding of their life situation before coming back around to the topic

Miller, William R.; Rollnick, Stephen. Motivational Interviewing, Third Edition (Applications of Motivational Interviewing) (Kindle Locations 940-942). Guilford Publications. Kindle Edition.

Question 44

Disengagement Trap 4: The Labeling Trap

Answer 44

basically a specific form of the premature focus trap. You want to focus on a particular problem, and you call it (or the client) by a name. Counselors and clients can easily be ensnared by the issue of diagnostic labeling. Some believe that it is terribly important for a person to accept (even “admit”) the clinician’s diagnosis (“ You have diabetes,” “You’re an alcoholic,” “You’re in denial,” etc.). Because such labels often carry a stigma in the public mind, it is not surprising that people with reasonable self-esteem resist them.

We recommend, therefore, that you de-emphasize labeling in the course of MI. Problems can be fully explored without attaching labels that evoke unnecessary discord. If the issue of labeling never comes up it is not necessary to raise it. Often, however, a person will raise the issue, and how you respond can be quite important. We recommend a combination of reflection and reframing

Question 45

Disengagement Trap 5: The Blaming Trap

Answer 45

a client’s concern with and defensiveness about blaming. Whose fault is the problem? Who’s to blame? If this issue is not dealt with properly, time and energy can be wasted on needless defensiveness. One obvious approach here is to render blame irrelevant within the counseling context. Usually this can be dealt with by reflecting and reframing the person’s concerns. If this problem arises, for example, the person may be told: “It sounds like you’re worried about who’s to blame here. I should explain that counseling is not about deciding who is at fault. That’s what judges do, but not good counselors. Counseling has a no-fault policy. I’m not interested in looking for who’s to blame, but rather what’s troubling you, and what you might be able to do about it.” Concerns about blame may also be averted by offering a brief structuring statement like this at the beginning of counseling.

Question 46

Disengagement Trap 6: The Chat Trap

Answer 46

Finally, it is possible to fall into the trap of just chatting, of having insufficient direction to the conversation. Making “small talk” may seem like a friendly opener, and no doubt it can have an ice-breaking function sometimes. In some cultures, a certain amount of chatting is polite and expected before getting down to business. Although off-topic chat can feel comfortable, it’s not likely to be very helpful beyond modest doses. In one treatment study, higher levels of in-session informal chat predicted lower levels of client motivation for change and retention (Bamatter et al., 2010). In the engaging process, primary attention is devoted to the client’s concerns and goals.

Question 47

Promoting Engagement

Answer 47

1. [desires and Goals] Why is the person coming to see you now? What does he or she want? Ask and listen.
2. [Importance] What is your sense of how important the client’s goal( s) may be?
3. [Positivity] Be welcoming. Offer a cup of coffee. Look for what you can genuinely appreciate and comment positively about, even something simple, and for other ways to help the client feel welcome.
4. [Expectations] How does the person think you might be able to help? Provide the client with some sense of what to expect.
5. [Hope] Offer hope. Explain what you do and how it may help. Present a positive and honest picture of changes that others have made and of the efficacy of the services you can offer.

Question 48

How does active listening help?

Answer 48

it is useful for clients to explore their own experiences and perceptions. Healing is not primarily a process of dispensing expertise. The opportunity to follow and reflect on one’s own experience is valuable, and it often gets derailed in ordinary conversation. Good listening helps a person keep going, to continue considering and exploring what may be uncomfortable material. Accurate empathy is a very good skill to facilitate such self-exploration.

Question 49

What kind of questions should we ask during active listening

Answer 49

Responses and questions that promote self-exploration

Question 50

Why respond with statements rather than questions?

Answer 50

The reason for responding with a statement rather than asking a question is a practical one: a well-formed reflective statement is less likely than a question to evoke defensiveness and more likely to encourage continued exploration.

Question 51

What is reflective listening

Answer 51

Reflective listening, then, involves responding to the speaker with a statement that is not a roadblock, but rather is one’s guess about what the person means.

It’s possible to turn almost any question into a reflective statement. When you’re first practicing, one way to form a reflection is first to think the question, “Do you mean that you . . . ?” Then remove the question words at the front (“ Do you mean that”) and inflect your voice downward at the end to make a statement.

Question 52

Different kinds of reflections

Answer 52

1. Simple Reflection: Parrot Phrasing

2. Complex Reflection: Continuing the paragraph,

Question 53

Difference between simple and complex reflections

Answer 53

A simple reflection is limited to what shows above the water, the content that has actually been expressed, whereas a complex reflection makes a guess about what lies beneath the surface.

Question 54

When using reflections why is it better to undershoot than overshoot

Answer 54

As a general principle, if you overstate the intensity of an expressed emotion, the person will tend to deny and minimize it, backing off from the original statement. On the other hand, if you slightly understate the expressed intensity of emotion, the person is more likely to continue exploring and telling you about it. When reflecting emotion, err on the side of undershooting if you want the person to continue exploring it:

Question 55

Was Carl Rogers truly non-directive in his approach with clients?

Answer 55

Carl Rogers maintained that he was nondirective in counseling, but his student Charles Truax (1966) coded audiotapes of Rogers’s sessions and found that he was differentially “reinforcing” certain kinds of client statements while letting others pass without reflection or comment. It is truly difficult to respond unconditionally to whatever clients say. It is easy, though, to be unaware of how one is influencing direction.

Question 56

If it is not possible to be truly non-directive, then how should questions and reflections be applied?

Answer 56

In the direction of accelerating change

Question 57

How to avoid the question-answer trap in the engagement process

Answer 57

follow each question with two or three reflections, to encourage the person to reflect on their answers

Question 58

Affirming

Answer 58

to accentuate the positive. To affirm is to recognize and acknowledge that which is good including the individual’s inherent worth as a fellow human being.

People are more likely to spend time with, trust, listen to, and be open with people who recognize and affirm their strengths.

It also increases openess