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CFN9885 - SECTION 11: MOTIVATIONAL INTERVIEWING

 

In order to address motivation for change, Miller and Rollnick (2002:30) have developed what they call motivational interviewing (MI). They define motivational interviewing as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”

Motivational interviewing draws on the person-centered model of counseling developed by Carl Rogers. Rogers believed in the client’s ability to move forward in a constructive manner if the appropriate conditions fostering growth are present. He firmly believed that people are trustworthy, resourceful, capable of self-understanding and self-direction, able to make constructive changes, and able to live effective and productive lives.

When clinicians are able to experience and communicate their realness, caring, and nonjudgmental understanding, significant changes in the client are most likely to occur.

Rogers maintained that three clinician attributes create a growth-promoting climate in which individuals can move forward and become what they are capable of becoming. These attributes are 1) congruence (genuineness or realness), 2) unconditional positive regard (acceptance and caring), and 3) accurate empathic understanding (an ability to grasp the subjective world of another person).

Rogers believed if these attitudes are communicated by the clinician, those being helped will become less defensive and more open to themselves and their world, and they will behave in pro-social and constructive ways. (Corey, 2001)

The principles of Motivational Interviewing can be summarized thusly:

- Change occurs naturally
- Motivation can be influenced by many naturally occurring interpersonal and intrapersonal factors as well as formal interventions
- What happens during and after formal interventions (treatment, counseling, education, etc.) mirrors natural change, rather than being a unique form of change
- The likelihood that change will occur is strongly influenced by interpersonal interactions
- When behavior change occurs within a course of treatment, much of it happens within the first few sessions, and, on average, the total dose of treatment does not make all that much difference
- The clinician is a significant determinant of treatment dropout, retention, adherence, and outcome
- People who believe that they are likely to change do so and people whose clinicians believe that they are likely to change do so
- What people say about change is important, in that statements that reflect motivation for - and commitment to - change do predict subsequent behavior change (Miller & Rollnick, 2002)


There are many ways to do motivational interviewing. The principles of motivational interviewing can be adapted to fit the clinician’s style of doing therapy, the counseling or treatment setting, and the characteristics of the client including where the client is in the stages of change in terms of their motivation for change.

However, clinicians who rely on information gathering as their most important task, who view their job as providing expert advice, frequently use confrontational tactics with their clients, and who are uncomfortable when clients remain ambivalent about changing their behavior might have a difficult time using motivational interviewing successfully.

There are four guiding principles that underlie motivational interviewing:

1) Expressing empathy by respectfully listening to people with a desire to understanding their perspectives
2) Creating and amplifying, from the person’s perspective, a discrepancy between present behavior and broader goals and values
3) Rolling with resistance by actively involving the person in the process of problem solving
4) Supporting self-efficacy by enhancing people’s belief in their ability to carry out and succeed with their plan for change.


Expressing Empathy

In motivational interviewing, the relationship between the clinician and the client is one of partnership, rather than expert-recipient. The approach is collaborative, not prescriptive. The focus is on the clinician evoking the person’s own intrinsic motivation and resources for change.

Clients bring to counseling or treatment an initial contribution, that is, their level of motivation for change. For most people there will be some amount of concern or intent to change, but some clients may have little motivation to change. Clinicians have a powerful potential to enhance the motivation their clients bring to the change process.

On the other hand, clinicians are not likely to elicit much motivation from a client who shows no or very little motivation to change. (Moyers & Waldorf, 2003)

There are six key elements in forming therapeutic alliances with clients and enhancing their motivation for change. The core elements are summarized by the acronym FRAMES: feedback, responsibility, advice, menu of options, empathy, and self-efficacy. (Yahne & Miller, 1999)

- Feedback: The clinician provides personalized feedback about the client’s current circumstances in terms of the health, psychological, and social consequences of their AOD use.
- Responsibility: The clinician stresses that, ultimately, responsibility for change rests with the client.
- Advice: The clinician offers clear and specific advice about the advantages of changing thoughts and behaviors as well as different ways that change can occur.
- Menu: The clinician provides a range of viable alternative strategies for changing thoughts and behaviors.
- Empathy: The clinician demonstrates concern for clients and affirms their experiences while supporting the changes they make.
- Self-efficacy: The clinician expresses confidence and nurtures the clients’ beliefs that they can carry out therapeutic tasks and meaningfully address their problems.


This does not mean that the clinician must always agree with their clients or approve all of their behavior. It is possible to understand and accept a person’s perspective while not agreeing with it or endorsing it. Neither does an attitude of acceptance prohibit the clinician from having a different viewpoint and expressing that divergence. The critical element is a respectful listening to the person with a desire to understand his/her perspective.

Interestingly, this basic therapeutic skill is often the most difficult to teach new clinicians. Most clinicians are taught that the goal of the initial session(s) is to ask a series of questions in order to be able to make an accurate assessment and treatment plan.

As a result, it can be difficult for some clinicians to focus on developing a good relationship with clients where clients feel understood and reveal information about themselves as they grow to trust the relationship. Using this approach may mean that it can take a number of sessions before all of the relevant information is revealed to allow an accurate assessment and treatment plan.

Developing Discrepancy

Motivational interviewing does not assume that people are always interested in changing their behavior. Failing health, interpersonal problems, the threat of fines, imprisonment, or loss of a job may deter many people from living with problems in their lives, but for other people it is just one of the risks or disadvantages that they are willing to accept as part of their current life situation.

What is highly valued by some people will be of little importance to others. While some people may not express any concerns about their problems, most people will have some internal concern if the behavior is truly causing them harm or the people around them harm. Most people will perceive a discrepancy between what is currently happening in their life and what they want to happen, but they may also be ambivalent about their desire to make the changes or they lack confidence in their ability to make the necessary changes.

Some people come to counseling or treatment having more or less decided they want to change, while other people will be reluctant or even hostile at the outset. Some people may have been coerced or mandated into treatment by family and friends, employer, school officials, social service officials, or legal authorities.

The clinician cannot impose a desire for change in the absence of some genuine concern within the person. The skill of the clinician is to understand why the person is reluctant to make changes and help the person find motivation for the changes to take place. (Moyers & Waldorf, 2003)

Discrepancy is fundamental to change. The discrepancy is generally between the person’s present situation and a desired goal with the larger the discrepancy, the greater the importance of change. The challenge is to first intensify and then resolve ambivalence by developing discrepancy between the client’s present situation and the desired future.

Change is facilitated by communicating with the client in a way that elicits the client’s own reasons for, and advantages of, change by talking about the disadvantages of the status quo, advantages of change, expressing confidence in the client’s ability to change, and strengthening the commitment to change.

Value and goal clarification exercises can also be an important part of developing discrepancy. Creating discrepancy can involve asking people to identify the goals they have for their life and then exploring with them ways in which some of their behaviors may be compromises these goals.

Some clients may be able to easily identify their values and goal, while other clients may find it more difficult. Additionally, some people can find it very difficult to articulate what is working and not working well in their life. To help clients articulate their values and goals, some client may find “value cards” very helpful (see http://casaa.unm.edu and the Personal Values Card Sort).

These are cards each of which is labeled with a particular value and the client sorts through the card to identify their values. After clients have identified their core values and goals, then the clinician can explore with the client on how their behavior may be compromising their values and goals.

Another way to develop discrepancy is to have the person write on a piece of paper the advantages and disadvantages of continuing to engage their current behavior(s) and the advantages and disadvantages of changing their behavior(s). When done correctly, motivational interviewing changes the person’s perceptions without creating any sense of being pressured or coerced.

This is because the discrepancy is between the person’s current behavior and their goals or values. In this way, the client is presenting the reasons for change, rather than the clinician or someone else.


Rolling with Resistance

Motivational interviewing says it is ambivalence, not client denial or resistance, that is the core issue for most people when they come to counseling or treatment. Most people face a struggle between wanting to continue with their behavior, while at the same time, wanting to stop or change the behavior.

A power struggle between the client and the clinician may actually have the effect of decreasing the client’s willingness to change. Coercion by itself rarely produces lasting change.

For most of people, there is a natural resistance to give up something that they are used to and they have come to value. If they are required or encouraged to give up something, even something they are ambivalent about, the more valuable it may become to them. Telling someone they cannot do something may in fact have the opposite effect of strengthening their commitment to the behavior.

Resistance is a fundamental part of most counseling and treatment. In fact, some clinicians argue that resistance is not a hindrance to counseling, it is the counseling.

How the clinician understands and responds to the resistance is what makes the difference. Faced with resistant clients, some clinicians will blame themselves. “If I were an effective clinician, I shouldn’t have clients who get stuck, or are uncooperative, or don’t come back for another session.”

In fact, clinicians may be influencing clients’ resistant behavior. It is very useful to explore what are some of the situations and ways in which you are most likely to resist in your own life and in dealing with your clients.

There are clients who - no matter what the clinician does - do not want to work on changing their problem behavior. However, for most clients there are many things that clinicians can do to address client resistance and help them to become motivated to make changes in their lives.

Motivational interviewing believes that it is the client who should be voicing the arguments for change and if clinicians find themselves in the role of arguing for change while their clients are arguing against it, they are in the wrong role. Motivational interviewing believes that client resistance behavior is a signal of dissonance in the counseling relationship. (Barnett, Monti, & Wood, 2001; Yahne & Miller, 1999)

There is some truth to the statement that we can “talk ourselves into change.” When clinicians wrestle with clients, one of them usually leaves the interaction frustrated and dissatisfied. If the clinician says to a person that “you’re a drug addict and you have to stop using drugs” you will often evoke a predictable response “I am not a drug addict, so I do not need to stop using drugs.”

Unfortunately, many clinicians have been trained to interpret this response as “denial” and they will push even harder to get the person to admit they are addicted to drugs.

Rather than challenging or directly confronting the resistance, the clinician should explore the reasons for the resistance. Clients may have some very good reasons for being ambivalent or resistant to making changes. Their ambivalence or resistance may be a sign that they fear reprisals from others for talking about their attitudes and behaviors, their previous experiences with clinicians or treatment personnel have been disappointing or hurtful and they do not understand or trust the counseling process, they have a strong belief that their situation is hopeless or other people will not understand them, and/or the counseling is bring up sensitive issues that they are no ready to explore.

Rolling with the resistance involves accepting a client’s reluctance and ambivalence. This approach assumes that the person is a capable and autonomous individual, with important insights and ideas for the solution of his/her own problems. The clinician does not impose goals; rather the person is invited to consider new information and perspectives in addressing their concerns.

An appropriate metaphor is piloting a boat on a rapidly moving river. The best strategy is often not to steer directly against the force of the water, but position the boat to take best advantage of the river’s energy and the boat’s capabilities. Another analogy is that the relationship between the clinician and the client should be more like dancing with the client and the leading is subtle and not readily apparent.

It is important to remember that ambivalence and resistance, like motivation and self-efficacy, is change-specific. For example, a person may be quite motivated to stop using cocaine, but unconcerned about their alcohol and marijuana use. A couple might be very motivated to learn how to stop arguing in front of their children, but they may be unwilling to address the hurt and anger that underlines the arguments.

It is important to remember, it takes courage for people to address sensitive issues in their lives and sometimes they do get justifiably defensive or resistant.

There may be situations where challenging or confronting a client may be appropriate. Confrontation as used in counseling is an intervention in which the clinician verbalizes the discrepancies, contradictions, and omissions expressed in the client’s words or actions.

The discrepancies or contradictions could be between the client’s perceptions and accurate information, between client’s expectations and likely possibilities, between client’s verbal and body messages, between client’s behaviors and stated goals, between client’s statements and actions, and client is omitting important information. Directly confronting clients’ defenses is probably the most risky kind of confrontation.

It is important to remember that defenses help people to tolerate the stresses and pains of life. On the other hand, these defenses may also prevent people from finding solutions to their problems.

Even so, most clients will resist giving up their defenses. Rather than confronting clients about their defenses, the clinician helps the client to see and experience them with greater clarity and helps clients to develop better problem-solving and coping behaviors. (Welfel & Patterson, 2005)

A key part of being empathic and skillful as a therapist is knowing when and how to confront or challenge clients. This involves knowing which clients may be helpfully challenged and when to helpfully challenge clients. Confrontation or challenging is done for and with the client, not to and against the client.

What this means is that clinicians do not confront to satisfy their own needs, to vent feelings of frustration, or to hurt clients. Rather, clinicians hold a sincere belief that clients will benefit by paying attention to some discrepancy or incongruence they have revealed. Confrontation should be used infrequently. In general, confrontation works best in the context of a trusting relationship where the client feels understood and cared about. (Egan, 1986)

Confrontation works best when you apply to following concepts:

- Be clear about your reasons for confronting: Have a plan for what you are trying to accomplish.
- Avoid labeling: Derogatory labels make clients feel put down and increase resistance to feedback.
- Describe the situation and the relevant behaviors: Describe the context and self-limiting behaviors as specifically and accurately as possible.
- Describe the impact or consequences of the behavior: Point out how relevant parties are affected by the behavior in terms of both emotions and behavior.
- Help clients identify what they need to do to manage the problem: Help the client to explore alternatives ways to respond to or manage the problem.
- Be willing to admit that a confrontation may be wrong: Not all denial is resistance and the client may have good reasons for having the feelings and engaging in the behavior that is being challenged.


Supporting Self-Efficacy

People are often resistant to change because they do not have much, if any, confidence they can take the necessary steps to change. The phrase “ready, willing, and able” is very appropriate when it comes to making changes. People may strongly desire change, but perceive that it is beyond their reach, they lack the confidence to reach it, or they have failed in past efforts to change the behavior.

It is important to understand what a person perceives and expects to be the outcome of different courses of action, including continuing what they are doing and trying something different. Asking a person a simple question such as: “On a scale from 0 to 10, where 0 is not at all confident and 10 is extremely confident, where would you say you are in terms of your confidence in changing this behavior?” This could be followed up with such open-end questions as, “What would it take for you to go from _____ to _____ (a higher number)?”

These expectancies can have a powerful effect on behavior. People who desperately want to stop smoking may still make no effort to do so because they have tried in the past to stop with little success and they believe that future efforts will be futile.

Clinicians might ask them a question like this one: “When in your life have you made up your mind to do something that was difficult and did it? How were you able to do it?” “What is there about you that could help you succeed in making this change?”

To assume that a person is responsible for deciding and directing his/her own life is to assume that the person is capable of doing so. Clinicians need to communicate to their clients that they are confident they can make meaningful changes in the lives.

It is important for the clinician and the client to develop change goals that are realistic and can be accomplished. It is often the case that there are multiple ways to approach a desired goal.

For example, a person with elevated blood pressure might consider dietary changes, weight loss, stress reduction, increased exercise, and/or medication. Getting some exercise such as walking around the block may be easier for a person to accomplish initially than going on a restrictive diet.

Giving a person options, especially at the beginning of treatment, may increase their chances of success and it may make them more willing to tackle more difficult problems further on. While the clinician and the client may have ultimate goals that they want to reach (i.e., stop all drinking and drug use, find a new job, become a healthy person, become a self-confident person, improve their marriage), there should be proximate, intermediate goals that are attainable along the way (i.e., reduce or eliminate use of particularly danger drugs, explore job options, get some exercise and lose 10 pounds, develop the courage to speak to your employer around your job, have dinner twice a week as a family.)



Motivational Interviewing Case Example

CLINICIAN: On the phone you said that you recently got arrested for driving while intoxicated and you thought that it might help your case if you got some counseling before your court date. Is this why you came to see me today?

CINDY: I came to see you because I did get arrested for drunk driving. We were celebrating my roommate’s birthday at a bar and I’d had too much to drink and I shouldn’t have driven home. I made a mistake, but I’m not an alcoholic. My friend told me it would look good to the judge if I went to see a clinician before my court date.

CLINICIAN: Let me see if I understand why you are here. You drank too much and you got arrested for drunk driving and you are hoping that seeing me will help you in your court case. But you do not think you have serious problem with your drinking.

CINDY: Yeah, I had too much to drink and I didn’t want to leave my car in the parking lot, so I took a chance and drove home. I made a mistake, a big mistake. But big deal, it’s not the first time I have driven after I have been drinking. Most everyone I know has had too much to drink and driven at least once. I just got caught. It’s so unfair.

CLINICIAN: So you made a mistake and took a chance with your drinking and drove home, but you don’t feel that your drinking is serious enough for you to consider it a problem.

CINDY: Some of my friends have told me that I have a serious drinking problem, that I may be an alcoholic, but what do they know. They have their own problems to worry about.

CLINICIAN: Cindy, let’s put aside categorizing or diagnosing whether or not you are an alcoholic for now. I’m more interested in hearing your concerns about your drinking and the problems it may be causing you and any other concerns you might have.

CINDY: What do you mean?

CLINICIAN: From what you said, it seems that some people are telling you they feel you have a drinking problem. You have told them and me that you don’t feel you have a drinking problem. It sounds like getting arrested was an upsetting experience for you. Are there things in your life, including your drinking, that concern you?

CINDY: It was very humiliating to get pulled over, arrested, and taken to the police station. My parents don’t know yet, but I am probably going to have to tell them. From what the police told me, they’re probably going to take away my license, make me pay a fine, and I’m going to have to go to DWI school. I’m probably going to have to get a lawyer to defend me in court. I don’t know how I’m going to get to my job and I don’t know if I can afford the fine and hiring a lawyer. One of the most embarrassing parts of all of this is having everyone know about it. I know that I sometimes drink too much, but I don’t think I’m an alcoholic. It’s not like I ended up passed out on the street like a homeless person.

CLINICIAN: So I hear you saying that you’re embarrassed by what has happened, you’re concerned about losing your license and the money you are going to have to spend on your court case, and you’re afraid of your friend’s and parent’s reaction. Is there anything else that’s bothering you or you’re concerned about?

CINDY: When they arrested me my blood alcohol level was .20 which is over twice the legal limit. I knew I was drinking a lot, but I did not think I had drunk that much. I was drunker than I thought.

CLINICIAN: It bothers you that you could be so drunk and not really be aware of how much you’d been drinking?

CINDY: Yeah, I never saw myself as a drunk driver, but I was really drunk that night and I shouldn’t have thought I could safely drive home. I’m just glad I did not hurt myself or hurt someone else.

CLINICIAN: When you think about yourself, you don’t think of yourself as a person who’d drive while that intoxicated. Is that what you’re saying?

CINDY: When I was a kid, my dad was an alcoholic and he was always drinking and driving and it use to make me so scared. I swore I would never get a DWI. I still can’t believe I thought I could drink that much and drive. What was I thinking?

CLINICIAN: Are you saying it’s hard for you to believe you’re might be like your dad in this way?

CINDY: I love my dad, but I swore I would not become a drunk like he use to be before he quit drinking. I think this is why my family has been so concerned about me lately. Lately they have been telling me that I seem to be either angry or distant most of the time and they are concerned about me. I need to make sure that I do not get arrested again. But I don’t need counseling or a treatment program to learn to control my drinking. I’m just going to do it on my own.

CLINICIAN: So you’re saying you don’t need counseling or a treatment program. So how can I be of help to you in this situation?

CINDY: What I need right now is something from you that will help me in court and I was hoping you could write up an evaluation of me to give to the court which would help get my sentenced reduced.

CLINICIAN: I might be able to help you in your court case, but if you want me to just ask you a bunch of questions and give you an evaluation for the court I probably cannot help you. But I also hear you saying that you do have some concerns about your drinking and this recent drunk driving arrest has you concerned that you may not be in control of your drinking and you don’t know why. I also hear you telling me that your family and friends have expressed concerns about what is currently happening in your life.

CINDY: Yeah, that’s probably true. I wouldn’t mind talking with someone about what is going on in my life, but I don’t think I need to be in a treatment program or completely stop drinking.

CLINICIAN: I think I understand. Would you be willing to talk with me about your life in a little more detail? I’d like to know more about you, what are your goals in life, what is currently working and not working in your life, and any changes you might like to make in your life.

CINDY: Yes, I wouldn’t mind doing that, maybe it would help.

Cindy and the clinician then talk about what she likes and dislikes about her current life, the positive and negative aspects of her drinking, and how her drinking may be compromising some of the values and goals she has for her life. The clinician is careful not to try to push, persuade, or argue with Cindy about the negative aspects of her drinking. Rather, the clinician’s goal is to get Cindy to express herself how she might benefit in making some changes in her drinking and in other areas of her life.

CLINICIAN: Cindy, I want to thank you for coming to see me today and sharing this information with me. It takes a lot of courage to tell a stranger like me about such personal things in your life. It has been very helpful in allowing me understand you better. Let me see if I understand what you have told me. You don’t like your job and wish you could go back to college and get a more rewarding job. You do like to drink, but you don’t drink everyday. You do most of your drinking with friends either after work or on weekends. Drinking helps you to relax and you enjoy drinking with your friends. You do see some problems with your drinking. Lately you have been drinking more and you have been drinking more by yourself. You don’t want to end up an alcoholic like your dad. You do see that it would be good for you to make some changes, but you also feel you drink responsibly most of the time and you don’t feel it is necessary to give up drinking for the rest of your life. What’s bothering you the most is that some people are trying to convince you that you have a significant drinking problem, that you may be an alcoholic, and this just doesn’t make sense to you. You appreciate that your family and some of your friends are concerned about you, but you feel that they do not truly understand you. You know if you put your mind to it you can get better control over your drinking and in other areas of your life, but you are having some doubts. Did I get it right?

CINDY: Yeah. It’s strange hearing it all laid out like that. When you put that way, it seems like I am saying that I feel I need to makes some changes in my life before it gets to be a worse problem.

CLINICIAN: Is that what you’re saying?

CINDY: Yeah.

CLINICIAN: What changes would you like to make in your life?

CINDY and the clinician then discuss some of the changes she would like to make in her life and future sessions would be oriented around discussing and trying to make these changes. It is possible that Cindy might conclude that he can make these changes on her own or without help from the clinician or she is not ready to make significant changes at this time. The clinician should not pressure Cindy to continue counseling with her, but the clinician should offer her services or give appropriate referrals for immediate or future use (Moyers & Waldorf, 2003).


Motivational Interviewing Techniques

Motivational interviewing has two basic phases. In the first phase the emphasis is on building motivation for change and in the second phase the emphasis is on strengthening the commitment to change through setting goals, considering change options, developing a plan, and eliciting commitment. Motivational interviewing focuses on helping to motivate individuals toward making changes using such strategies or techniques such as:

- Normalizing client uncertainties
- Rolling with resistance
- Asking open-ended questions
- Discovering client’s beliefs
- Reflective listing
- Conducting empathetic assessments
- Amplifying client doubts
- Developing discrepancy between person goals and problem behavior
- Conveying confidence in client’s abilities to change
- Supporting client choice and self-efficacy
- Reviewing past treatment experiences
- Working with client to develop a treatment plan
- Providing relevant feedback
- Summarizing and reviewing potential sources of non-adherence
- Negotiating proximal goals
- Discovering potential roadblocks
- Displaying optimism
- Involving supportive significant others


People come to counseling with a wide variety of expectations. So it is important at the outset to provide the client with a simple and brief introduction as to what will happen during the first and subsequent sessions. Clinicians might try something like this:

Today we have about an hour together and my primary goal during this first session is to get an understanding of what bring you here. While I will probably ask you some questions, I will spend most of the time we have together listening to what you have to say so that I can better understand you and your concerns. You probably have questions you would like to ask me and I will try to answer them. You probably have expectations about what will and won’t happen here, and I’ll want to hear about your expectations and goals for our work together. Toward the end of the session, I’ll probably want to ask you for some specific information that I will need, but let’s just get started for now. What’s on your mind?


At this first session, the client should do most of the talking with the clinician listening carefully and encouraging expression. One key for encouraging clients to do most of the talking is to ask open-end questions such as: “I understand you have some concerns about _______. Tell me about these concerns.” “You said when we spoke on the telephone that you have been having trouble with _______. What kind of troubles have you been having?”
Once you have asked an open-ended question, respond to the client’s answers with reflective listening. You should not follow-up an open-end question immediately with another open-end question. You need to give the person time to respond and to get into the flow of how the sessions will take place.

Examples of Open-Ended Questions to Evoke Change Talk

Disadvantage of the status quo
In what way does this concern you?
How has this stopped you from doing what you want to do in life?
What do you think will happen if you don’t stop or change anything?
How do your friends and family feel about it?
What difficulties have you had in relationship to your _____?

Advantages of change
How would you like things to be different?
What would be the advantages of making this change?
What would be the good things about _____?
If you were to wake up tomorrow and everything would be the way you wanted it to be, what would it look like?
What would you like to be doing 5 or 10 years from now?

Optimism about change
If you decided to change, what do you think would be a good first step?
How confident are you that you can make this change?
What personal strengths do you have that will help you succeed?
Are there people in your life that could support you in making this change?
What encourages you to think that you can change if you wanted to?

Intention to change
Right now, how important is this to you?
What do you think you might do first?
Of the options we have discussed, which one sounds like it would work best for you?
I can see that you’re feeling kind of stuck at the moment. What’s going to need to happen to get you unstuck?
Is there anything that I can do, or your friends or family can do, to you help you? (Miller & Rollnick, 2002)


At strategic times during the session, especially after the person has voice some potential change talk, it is important to summarize your understanding of what has been said so far. Such summaries reinforce what has been said, show that you have been listening carefully and understand what the person is saying, and it prepares the client to elaborate further. There are at least three kinds of summaries.

A collecting summary summarize what has been talked about so far. They are usually short, just a few sentences, and they should continue rather than interrupt what the person has been saying. They encourage the person keep talking. For example, the clinician might say: “Let me see if I understood what you have told me so far.”

A linking summary ties together what a person has just been saying with material offered earlier. They are designed to encourage the client to reflect on the relationship between two or more things they have said. For example, the clinician might say: “It sounds like you’re going in two different directions. On the one hand, you’re worried about ______, but on the other hand, you’re not concerned about _____.”

Finally there is the transitional summary, which marks a shift from one focus to another. For example, the clinician might say: “We are about out of time and I’d like to pull together what you’ve said so far, so we can see where we are and where we’re going. Please let me know if I miss anything important that we’ve covered or I misstate what you have said.” At the end of the summary you should ask: “Is that a fair summary of what we have talked about so far and where we are? Have I missed anything?”

What happens in the first few counseling sessions is very important not only in terms of whether or not the client will continue in counseling or treatment, but the first few sessions also sent the stage for what will happen in future sessions. In these first few sessions, if nothing else, it is important for the client to perceive the clinician as interested in them and competent to meaningfully help them to address the reasons they are in counseling or treatment.

Miller and Rollnick (2002) offer these practice guidelines for using motivational interviewing:

- Talk less than your client
- Offer two to three reflections for every question that you ask
- Ask twice as many open questions as closed questions
- When you listen empathically, more than half of the reflections you offer should be deeper, more complex reflections (paraphrase) rather than simpler repetition or rephrasing of what the client offered.

They conclude by saying that the overall point is to pay attention to clients with both your eyes and ears, being open to the fact that what clients are saying and how they say it is not simply arising from within, but it is in large measure a dynamic response to the clinician’s behavior as well. Clients should be the guide and teacher.


Types of Motivational Interviewing

Motivational interviewing can be used in a number of ways. First, it can be used in what is often called brief interventions. Brief interventions have been developed to target individuals who experience early or at-risk problems.

The basic components of brief interventions typically involve a 15-30 minute interview involving a brief screening and assessment, feedback on personal risk, advice about how to change the behavior, assessing motivation for change, exploring education and treatment options, a referral for further counseling or treatment if warranted and desired, and, in some cases, follow-up sessions. These types of sessions have been used very successfully in emergency rooms and other medical settings, police stations, schools, personnel offices, and churches.

For some people, just one session may be enough to start them on the road to recovery either on their own or with the help of others. For other people, one session may plant the seed for sometime in the future when they are more willing and able to address their problems. This technique can be used for a variety of problems by a variety of health care and non-health care professionals including primary care doctors and nurses, dentists, psychologists, social workers, marriage and family therapists, ministers, and trained lay-people. (Barnett, Monti, & Wood, 2001)

Motivational interviewing can also be used to increase client motivation for other types of treatment including more intensive treatment such as structured outpatient or residential programs. The Institute of Medicine (1990) recommends greater use of community resources to identify people with problems, to provide brief interventions to those with mild to moderate problems, and to refer those with more severe problems to specialized treatment programs.

This approach could promote earlier treatment entry for those who need it and could reach untreated problem users who avoid traditional, intensive treatment or who dislike features of self-help groups. In this strategy, the clinician meets with the client for several sessions to develop a relationship, assess the nature of the problem(s), and what changes the client wishes to make.

If the client wishes to make changes then there is a discussion of treatment options, giving the client information about the pros and cons of the different options. The client can then use this information to make an informed choice about whether or not to pursue further counseling or treatment.

Finally, motivational interviewing can also be used as a stand alone approach. There is a motivational interviewing manual that has been developed for people with alcohol and other substance use problems. (Miller, Zweben, DiClemente, & Rycharik, 1995)

The manual divides the therapy into three phases. Phase one focuses on developing client’s motivation for change. The clinician’s primary task is to shift the focus from perceived benefits of continued use to feared consequences of use by providing objective feedback from the client assessment, reflections on the problems associated with substance use, and amplifying discrepancies.

The second phase tries to consolidate the commitment to change through a change plan. The Change Plan Worksheet asks clients to identify: 1) the changes I want to make, 2) the most important reasons why I want to make these changes are. 3) the steps I plan to take in changing are, 4) the way other people can help me are, 5) I will know that my plan is working if, and 6) some things that could interfere with my plan are.

The third phase focuses on reviewing the progress of the change plan and obstacles that have arisen in achieving goals.

 

 

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