Motivational Interviewing Flashcards
Definitions of
Motivational Interviewing
Motivational Interviewing is a person-centred counselling style for addressing the common problem of ambivalence about change
Motivational Interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.”
Motivational interviewing is a collaborative, goal
orientated style of communication with particular
attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance & compassion
William Miller and Stephen Rollnick Motivational Interviewing (3rd Edition).
Will & Way
Two aspects of readiness
to change
If you want to build a ship, don’t drum up the men to gather wood, divide the work and give orders.
Instead, teach them to yearn for the vast and endless sea. Antoine de Saint Exupery - The Wisdom of the French writer (1900 1944).
And at the same time If you merely increase a person’s urgency for change but not their belief that it is possible, you haven’t done them any favor.
Do Not
ASIST
Advise
Suggest
Interpret
Solve
Tell
What are the four key elements
for the Spirit (or philosophy) of MI?
PACE
MI is a person-centered counseling method for
addressing the common problem of ambivalence about change.
Four key elements:
- *Partnership** (each of you brings expertise)
- *Acceptance** (their life, their choice)
- *Compassion** (acting in their interests, not manipulation)
- *Evocative** (drawing out from them).
What is the sessional framework of an MI session?
EFEP
Engaging
Focusing
Evoking
Planning
What are the main strategies in
Motivational (Reflective) Interviewing?
EFEP
Engagement (Who?): Getting on the same page, who are they, why are they here? what’s important to them? Building empathy, trust and rapport
Focusing (What?): an ongoing process of seeking and maintaining direction.
Evoking (Why?): tapping into and drawing out deeper resources of motivation and confidence
Planning (How?): mapping out specific steps towards achievable WHO? desired goals
OARS
Core Tools of Motivational Interviewing
Open ended Questions - like a door opening into new ground. They invite someone to reflect and elaborate, helping us understand their view and what is important to them. eg what would make you pleased you came?
Affirming - when you notice them use a strength or take a positive step, recognise that. Affirming supports the growth of confidence and trust.
Reflective listening - this is at the heart of motivational interviewing. Simple reflections echo back what you hear, complex reflections reflect back deeper meanings or multiple elements in what you hear.
Summarising - using longer reflections to gather together aspects of what has been said. Collect what they say and offer it back.
Elicit
Provide
Elicit
Whatever meaty information you provide is sandwiched between two wholesome slices of asking.
- *Elicit** – ask permission, clarify information needs and gaps. What do you know already? What would you like?
- *Provide** – share feedback or information, offer, invite, leave them to choose how to use
- *Elicit** – check how it has landed – what sense they make of it, how they might respond
Prokashka
Change Model
Consonance
Dissonance
A relational understanding of resistance
Move from ‘they’re resistant’ to ‘there’s a gap between us’
Consonance – agreement or compatibility between opinions and actions, harmony between musical notes
Dissonance – lack of agreement or harmony between people or things or musical notes
Insight 3 – see resistance as a signal that you might be jumping ahead of your client.
Eliciting
Change Talk
Consider what ‘stage of change’ are they at
Nudge
Listen
Summarise
See your first task as to understand your patient’s
dilemma and then to reflect this back to them.
This is ‘expressing empathy’
What are three types
of Reflective Listening?
the primary skill of MI
You take in your understanding of what they’ve said and reflect it back to them
This shows interest and expresses empathy
Above the surface what they say
Beneath the surface – thoughts, feelings and beliefs behind what they say
Simple Reflection
repeating back what they’ve said
Complex Reflection - taking a guess at what you think they mean or feel, reflecting what’s below the surface.
Doublesided reflection reflecting both sides
of their ambivalence
Reflection Types
Much of what is needed is already there
it’s a matter of drawing it out, calling it forth
Selective reflection ‘You had intended to try it out’
Evocative question ‘what would make this more
- *Culture setting statement** that emphasises their choice coupled with…
- *Double sided reflection** ––‘I hear you’re not keen on this, but part of you can see some reasons here’ (re smoking)
Reflective Listening
It is a way of shining a spotlight on particular elements of what they say.
The combination of open ended sentences and reflection draws them out, making it easier for them to tell you what’s under the surface for them.
In engagement reflecting helps check and build your understanding.
With evoking and planning processes reflection can be more selective.
What are the the 2 levels
of reflective Listening?
Understand what they’ve said and reflect it back to them. Show interest and expresses empathy
Notice the above the surface what they say
Notice the beneath the surface – thoughts, feelings and beliefs behind what they say
What are the three Focusing Styles?
Directing – you set the agenda – “this is where we’re going”
Following – client-centred - “which way would you like to go?”
Guiding – lies between the above two styles, with a collaborativeprocess of finding mutually agreeable direction
Agenda Mapping
Unfolding Process
Developing & maintaining a specific agenda
Discovering what’s important for the client.
The goal may be unclear – you explore more and draw out pieces of the puzzle.
The goal may be clear – confirm this, then move to evoking
There may be a range of options – agenda mapping is useful
Change Talk
Key predictor of change is balance between change talk and sustain talk.
If change talk increases during a session, the patient is more likely to change.
Our conversational style can influence this
Sustain talk - Any talk that resists change
and supports the status quo
Change talk - Any talk that supports change and
opposes the status quo
What is DARN?
Preparatory
Change Side ofambivalence
Desire I want to, would like to etc
Ability I can, this is possible for me
Reasons if… then…, seeing benefits
Need imperative language, I must, I should…
Types of Change Talk
DARN Questions
Evocative Questions
Desire
What do you hope our work together will accomplish?
What don’t you like about how things are now?
Ability
If you really wanted to, how could you do this?
What ideas do you have for how you could …?
Reasons
Why do you want to..?
What could be the advantages of …?
What’s the downside of staying with same?
Need
What do you think has to change?
How serious or urgent does this feel for you?
What is CAT?
Mobilising Change Talk
Seeks to resolve ambivalence
through making change
Commitment I intend to, I will..
Activation I’m willing to, I’m ready to
Not a binding contract, but leaning towards change
Taking Steps already doing something in the direction of change
CAT
Questions
Commitment:
You’ve made a decision to address this…
Activation:
What are some steps you do feel ready to take?
Affirming
Taking Steps:
I want to acknowledge the step you’re taking
just by talking about this today.
Discrepancy
What feeds motivation?
Value Action Gap
Supporting someone to make their own
argument for change.
Discrepancy: an uncomfortable gap between
Find the want behind the should
Move from current state to preferred state
What is decisional balance?
Bringing ambivalence into view so that it can be worked with.
What are the advantages and disadvantages of
addressing this?
No change: Advantages vs Disadvantages
Change: Advantages vs Disadvantages
Planning
Shift from evoking to planning
Listening for clues and testing the water
Listening for clues
Increase in change talk
Reduction in sustain talk
Taking steps
Expressions of resolve
Questions about change
Envisioning
Recapitulation
A transitional summary
A pivotal moment after evoking
when you’re sensing they’re ready
Test the water with a key question
“So where does this leave you?
So what do you think you’ll do?
I wonder what you might decide to do?
What are your thoughts here?
EFEP
What are the four EFEP questions?
1) What was engagement like? are you seeking to understand their perspective? Do you have a collaborative stance that supports their autonomy?
2) Was there a clear focus? The focusing process of MI hones in on a specific topic of importance to them.
3) Are you evoking change talk? Looking out for it, asking questions that invite it, reflecting it when it is there, or drawing it out more.
4) Was there collaborative planning? Drawing out their ideas of how to move forward, if advice or information offered, check they’re interested first (eg EPE).
EFEP
Questions 2
1) Engagement: how well do I understand how this person perceives the situation or the dilemma? Can I give voice to what this person is experiencing?
2) Focusing: Do we have a shared sense of the direction we want to be moving in and the goals our conversation supports?
3) Evoking What do I know about this person’s motivations for change? Am I hearing change talk? What am I doing intentionally to evoke and strengthen change talk?
4) Planning Am I hearing mobilizing change talk that may signal readiness to discuss when and how change might occur, even a first step?
What are the four original
MI Principles
Express Empathy
Develop Discrepancy
Roll with Resistance / Avoid Argumentation
Support Self -efficacy
Resistance
Rolling
1) Emphasise personal choice
2) See resistance as difference not defiance
3) Be a mirror reflective listening
4) Amplified reflection
5) Double side reflection
6) Agreeing with a twist
7) Affirm strengths you see
8) Reframe/explore alternative perspectives
9) Consider options and shift focus
10) Open questions
DARNCAT
Questions
- D: Why do you want to make this change?
- A: How might you be able to do
- R: What is one good reason for making the change?
- N: How important is it, and why? (0-10)
- C: What do you intend to do?
- A: What are you ready or willing to
- T: What have you already done?
What is the
Spirit of MI?
Partnership: work collaboratively (avoid being the expert)
Acceptance: respecting autonomy, strengths & perspectives
Compassion: keep the best interests in mind
Evocation: the best ideas come from the client
Brief MI
Stan Steindl
- What would you like to change next (about..)?
- What would be the three best reason for making this change?
- What makes this change really improtant to you?
- If you were ot make this change how would you go about it?
- What will you do next?
Change Capacity Scaling
Bill Matulich
On a scale from 0 to 10 how important is it for
you to…?
On a scale from 0 to 10 how confident are
you…?
What are 3
“Helping”
Communication Styles
Following - seeing and understanding
the world through another’s eyes.
Directing - Appropriate when another
looks to you for decisions, actions,
advice.
Guiding - Helps another solve the
problem for himself.
How does Basic Human Nature
affect change?
Reactance: it is basic human nature to resist persuasion, especially about something you are
ambivalent about.
Self-perception: It is also basic human nature
to believe what we hear ourselves say.
Brief MI
• Why do you (might you) want to make this
change?
• How would you go about it in order to
succeed?
• What are the three best reasons to do it?
• What would some of the benefits be?
• How important is it for you? (on a scale of 1 to 10)
• What’s your next step if any?
Open Questions 1
• What concerns you about your situation?
• What is the best thing that could happen if you
changed?
• Where do you want to be in 5 years?
• What are some things you might do when you
decide to change?
• How confident are you? (on a scale of 1 to 10)
• What’s the smallest step you could take
Oliver Sacks
I find every patient I see,
everywhere, vividly alive, interesting
and rewarding: I have never seen a
patient who didn’t teach me
something new, or stir in me new
feelings and new
How do you encourage
engagement?
Feeling welcome
Feeling comfortable
Feeling understood
Exceeding expectations
Having mutual goals
Being hopeful
What good listening is NOT
The Assessment Trap
The Expert Trap
Premature Focus Trap
Labeling
Blaming
Chatting
“Roadblocks to Listening”
Advising, interpreting, telling, solving,
• Asking questions
• Agreeing, approving, or praising
• Advising, suggesting, providing solutions
• Arguing, persuading with logic, lecturing
• Analyzing or interpreting
• Assuring, sympathizing, or consoling
• Ordering, directing, or commanding
• Warning, cautioning, or threatening
• Moralizing, telling what they “should” do
• Disagreeing, judging, criticizing, blaming
• Shaming, ridiculing, or labeling
• Withdrawing, distracting, humoring, or
changing the subject.
How to form
Reflective Listening
Statements
Focusing all of one’s purpose, attention, and energy on understanding what the SPEAKER’S message means to the SPEAKER
Form a hypothesis of what the speaker means.
Voice inflection goes down at end of statement rather than up.
Reflections
Simple
Complex
Simple
• Repeat - simply repeat an element of what the speaker said.
• Rephrase - substitute synonyms or slightly rephrase what speaker says.
Complex
• Paraphrase - infer the meaning and reflect it back in new words, continue the paragraph.
• Reflection of Feeling - emphasizing the emotional
dimension with feeling statements, metaphor, etc.
• Double-sided - “On one hand _ on the other hand
Reflection Statements
Why Emphasize Reflection?
• Get more, and more valid information with
reflections than with questions.
• People feel listened to, understood, cared about with reflections.
• Speaker is empowered to lead the conversation.
• Whose agenda is it anyway?
• Less lying.
• Allows you to take client perspective.
- “It sounds like…
- “You’re wondering…
- “So, you are saying that…
- “You are feeling like…
- “Through your eyes…
- “That makes me think…
- “If I understand you correctly…
- “I get the impression that you…
How do you use affirmations?
To build feelings of self-efficacy and empowerment:
- strengths
- resources
- self-enhancing behavior
- personal achievements
- prior successes
- previous attempts
How to summarise
Gather the individual flowers and give
back a bouquet.
• Strategic - selectively choose what you want to
summarize.
• Linking - bringing together material discussed.
• Organising - enhances client understanding of their
experience.
• Reinforcing - reinforce what has been said.
• Transitional - shift from one focus to another.
Recognizing Change Talk
Darn Cat
- Desire: I want to…
- Ability: I can…
- Reason: It’s important…
- Need: If…then…
- Commitment: I will…
- Activation: I am ready…
- Taking Steps: I am doing it now.
Frame Matrix for Change
Towards
Thoughts———————- Actions
Away
Resistance feels like?
- You feel like you are fighting or arguing
- Your posture is more tense
- You are working harder than your clients are
- You dread the session
- You feel stressed, insecure, incompetent
- You are feeling “burned out” with your work.
Ways to “roll with resistance”
Reflection
Shifting Focus
Emphasizing personal choice & control
Why Reflection?
• Get more, and more valid information with
reflections than with questions.
• People feel listened to, understood, cared about with reflections.
• Speaker is empowered to lead the conversation.
• Whose agenda is it anyway?
• Less lying.
• Allows you to take client perspective.
What does
resistance feels like?
- You feel like you are fighting or arguing
- Your posture is more tense
- You are working harder than your clients are
- You dread the session
- You feel stressed, insecure, incompetent
- You are feeling “burned out” with your work.
Spirit of MI
Resist righting refelect
Understand the clients motivations
Listen with empathy
Empower the client
What are the Styles of MI?
Directing
Following
Guiding
What are the Skills of MI?
OARS
Open questions
Affirmations
Reflecions
Summaries
COCO
CONNECT
OFFER
CONNECT
OFFER
FRAMES
Feedback - “You’ve scored 16 on the AUDIT which indicates that you are at high risk of harm from your current pattern of drinking…”provide the patient or client with a verbal report card based on the results of your assessment or their score on the AUDIT screen.
Responsibility - “Nobody can make this choice for you. It’s really up to you to make a change…”
Advice - “…yet as your [doctor] I strongly advise you to limit your drinking or stop altogether to reduce the risks.”
Menu - provide a menu of strategies for changing drinking behaviours. Options include behavioural control
Empathy - brief interventions emphasise the development of a therapeutic alliance in the context of a warm, reflective, empathic, and collaborative approach by the practitioner.
Self-Efficacy - “Many people successfully control their drinking or stop drinking all together. With the right support and information I’m confident that you will do it too”. upport the person’s self-efficacy for change, and communicate a sense of optimism. De-emphasise helplessness or powerlessness.
