What MI is…



Engagement - Building rapport:

·      In MI the client-therapist relationship is in the forefront and it never left to chance or chemistry.

·      The MI therapist begins by developing trust, building rapport, by providing the client with an empathic, reflective, sounding-board so hey can hear what they say and feel heard.

·      The MI therapist will follow the spirit of MI by expressing empathy, respecting autonomy, assisting collaboration, reflecting genuineness.

·      The MI therapist will strive to create an atmosphere of safety and acceptance.

·      The MI therapist is careful not to address topics too soon, which could cause therapist-client dissonance and harm the MI relationship.



Goal Directed:

·      The MI therapist refers to identified goals, objectives and target behaviors.

·      The MI therapist attains clarity, through engagement, about the target behavior or goal being addressed, and then strives to keep the discussion focused on these targets in order to keep the communication focused and productive.

·      The MI therapist needs to be vigilant around the need to shift away from a topic when the client is expressing resistance or does not want to continue in this area.



The structure of a Goal-Directed discussion may be:

·      The client begins by discussing developmental issues or historical concerns that may cause pain and distress.

·      Once the discussion is complete, the MI therapist should begin to assist the client in discovering the relationship between the client’s history and their present goals.



Resolve ambivalence:

·      The MI therapist begins to facilitate the client’s exploration of ambivalence, with a discussion that emphasizes change talk and ‘tipping the balance’ towards behavior change.

·      The MI therapist begins to guide the client toward internal recognition about their behavior, whether their behavior is a problem, and helping the client reach a decision about change.



Menu of options:

·      The MI therapist assists the client in referring to a numerous actions that the client and provider collaboratively identify and agree to include in a behavior change plan.

·      The MI therapist uses a menu. This menu refers to the identification of six or seven specific actions that will be discussed.

·      The MI therapist places emphasis on the client’s willingness to pursue an identified action.

·      The MI therapist will only include actions on the plan that the client is willing to pursue.

·      The MI therapist will work with the client to assure the plan is fluid and capable of change.

·      The MI therapist prioritizes each action is directed toward confidence building while conveying the hope that change can be attained.



Pros and Cons:

·      The MI therapist uses this strategic intervention to assist with the exploration of the positive and negative experiences a client might have regarding a particular behavior.

·      The MI therapist uses this technique to elicit change talk when a client may not have identified any disadvantages voluntarily.

·      The MI therapist begins with an exploration of the positive experiences the client may have (This is known as “sustain talk”) until a level of comfort is reached and then they move on to what is “not so good” about the behavior.

·       The MI therapist assists the client, who is comfortable, to begin identifying elements of concern; either for the first time or in a way that is not resistant or guarded.

·       The MI therapist should place more emphasis on guiding the client to change talk, rather than involving themselves in “sustain talk.”

·       The MI therapist should always be concerned that “sustain talk” may be reinforcing and deflect from change talk.



The Decision Balance -- Not a required technique to practice MI (Miller & Rollnick, 2009).

This technique is not MI. It has been used routinely by some MI practitioners as a “required technique”, but is not formally recognized.



It is a form of identifying pros and cons within four quadrants.

Quadrant A -- What is good about continuing the behavior.

Quadrant C -- What is not good about changing the behavior.

Quadrant B -- What is not good about continuing the behavior.

Quadrant D -- What is good about changing the behavior.



Weight is given to Columns A+B as compared to columns C+D.

This technique currently has limited use in MI, because it offers little in the form of change talk.



Ask permission to give advice or information: AKA: Giving advice vs. Asking Permission.



Giving Advice: “AA groups would be good for you.”

Asking permission: “Would you be interested in hearing my ideas about what might be useful?”

If the client says yes, the practitioner might recommend AA or make other suggestions.



Providing an opportunity for the client to reject the suggestions:

“How do you think this might work for you?”

This allows the client pursues action only in areas agreed upon.



Giving Advice: “Read this information on the medication you are using.”

Asking permission: “Would you be interested in learning more about this medication?”

If yes, some written materials might be provided.



What MI is Not…

·      MI is not based on the transtheoretical model - the stages of change. They are two discrete models, and neither one requires the other;

·      MI is not a way to trick people to get them to do what they do not want to do;

·      MI is not a technique; it is more complex and better understood as a communication method;

·      MI is not the decision balance, this has been over utilized and misperceived as MI methodology;

·      MI does not require assessment feedback, this design is specific to MET;

·      MI is not a form of cognitive- behavior therapy, nothing is installed, rather MI elicits from people what is already there;

·      MI is not just client-centered counseling, it departs by being goal oriented and having intentional direction towards change;

·      MI is not easy, it involves a complex set of skills that are used flexibly;

·      MI is not what you are already doing, learning MI requires training, supervised practice and feedback; MI is not a panacea, it is not meant to be a school of psychotherapy, rather it is a particular tool for addressing a specific problem.



Metaphors that can be used during an MI session…

·      Ambivalence is a bit like having a committee inside your mind, with members who disagree on the proper course of action. (p. 7)

·      The partnership...conversation is a bit like sitting together on a sofa while the person pages through a life photo album. (p. 16)

·      Evocation...is like…drawing water from a well. (p. 21)

·      Planning is the clutch that engages the engine of change talk. (p. 30)

·      A simple reflection…is like an iceberg…it 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. (p. 58)

·      Practice without feedback…is like…golfing in pitch-black darkness. (p. 59)

·      A simple rhythm in MI is to ask an open question and then to reflect what the person says, perhaps two reflections per question, like a waltz. (p. 63)

·      Summaries are…strands that are woven together into a fabric, a single piece that contains all of their colors. (p. 69)

·      Summaries are like…seeing the forest instead of one tree at a time. (p. 69)

·      The focus is a light on the horizon toward which you keep moving. (p. 99)

·      MI is like dancing, moving together, in which you offer gentle guidance. (p. 103)

·      The smallest glimmer of change talk may be a coal that if given some air will start to glow, becoming the fuel of change. (p. 103)

·      Agenda mapping is like…examining a map at the outset of a journey. (p. 106)

·      This approach [agenda mapping] is like looking at a map and seeing the places you might go, perhaps like two people on a sailboat slowing down for a moment to agree on a new course before catching the wind again. (p. 106)

·      If the client’s life is like a forest, agenda mapping involves soaring over it for a moment with the perspective of an eagle. (p. 107)

·      Zooming in…is like pushing the plus (+) button to zoom in and get a better look at a particular area. (p. 108)

·      Agenda mapping can be…a matter of listening to the client’s story and puzzling together about a route out of the forest…where you may follow various streams to map the terrain (p. 116)

·      The interviewer is keeping the whole picture in focus (eagle view) rather than zooming down to a particular task (mouse view). (p. 116)

·      Change talk is a bit like walking up one side of a hill and down another. (p. 163)

·      MI helps people out of the forest of ambivalence…MI helps them to keep moving from tree to tree until at last they find their way out of the forest. (p. 166)

·      Early in an MI session the skill is often to discern a ray of change talk within the sustain talk, like spotting a lighthouse in a storm or detecting a signal within noise. It is not necessary to eliminate the storm or the noise, just follow the signal. (p. 178)

·      Discord is like fire (or at least smoke) in the therapeutic relationship. (p. 197)

·      Just as a smoke alarm alerts you to a change in the air, tune your ear to hear signals of dissonance and recognize them as important. (p. 204)

·      MI is like improvisational theater. No two sessions run exactly the same way. (p. 211)

·      As with motivation more generally, hope is evoked from within the client. The seeds of hope are already there, waiting to be uncovered and brought into the light. (p. 214)

·      Be careful not to give in to the righting reflex…that will shut [clients] down like alligator jaws. (p. 249)

·      Getting up on your soapbox tends to leave people with a soapy taste in the mouth. (p. 249)

·      Sometimes it moves quickly, but engaging, focusing, and evoking can be a slow step-by-step process like snowshoeing up the side of a mountain. The progress may be steady, but it feels effortful, there are likely to be a few backslides, and you have to pay attention to where you are going. (p. 257)

·      Planning…is more like a downhill ski…there is still the danger of running into trees, taking the wrong trail, or even heading off a cliff, so you still have to pay attention…(p. 257)

·      Mobilizing change talk…is language on the far side of the ambivalence hill…(p. 285)

·      You continue to explore the forest of change, moving from tree to tree in a reasonably straight line. Beneath the surface, seeds are germinating. (p. 289)

·      It can feel comfortable to take the lead [in a conversation], confident in one’s expertise, and it can also quite soon feel frustrating—a bit like pulling someone across the dance floor, trips and all. (p. 310)

·      Learning MI is like learning to fly an airplane…it is an on-going process and more than knowledge is involved. (p. 322)

·      Feedback is fundamental…It is difficult to learn archery in the dark. (p. 323)

·      Can you do MI in a few minutes? It is in a way like asking, Can you play the piano for 5 minutes? (p. 343)

·      Low-quality MI practice might be likened to half-doses of a vaccine or antibiotic: the right idea but insufficient strength. (p. 351)

·      An MI trainer should…be able to demonstrate it competently on the spot. It would be a rare violin teacher who cannot play the instrument competently. (p. 354).

·      While we hold a parental fondness for this growing child that we have nurtured, and entertain some worries for its future development, we have come far enough together to stand back in wonderment and curiosity to see what will happen next. (p. 402)



Motivational Interviewing, Third Edition: Helping People Change (Applications of Motivational Interviewing) William R. Miller, Stephen Rollnick. The Guilford Press; Third Edition (September 7, 2012)



A FANTASTIC MI Resource --- http://www.motivationalinterview.org

The True PRE-SOCIAL WORK Social Worker “She deserves an Honorary MSW!”

One hundred years ago, on January 18, 1914, Mrs. Emma L. Miller, the first matron and female employee in VHA’s early history, passed away.  She was a notable woman, not only because she was the first matron, but because  her lifelong devotion and service to Civil War veterans drew admiration from the men whom she took care of, and won her enough respect from the National Home for Disabled Volunteer Soldiers’ Board of Managers that they appointed her as the first woman officer in that organization—a rarity at the time.

Before the Civil War, Emma L. Miller lived a simple life as a young wife and mother moving with her husband from Pennsylvania, to Illinois, then settling in Ohio, as they chased the American dream.  All of that changed when she lost her husband during the American Civil War.  She, along with thousands of her Northern “sisters” who experienced the same loss—be it brother, son, husband, cousin, or friend—joined forces and funneled their grief into compassionate and fervent causes that rendered care and aid to soldiers who survived the war’s ravages.  She became very active in the Cincinnati and Cleveland branches of the U.S. Sanitary Commission, which was charged by Congress with providing medical care, support, and services to the Union’s volunteer forces.  After the war, in October 1865, when the State of Ohio established a soldier’s home in Columbus for sick and injured discharged soldiers, she was appointed as its matron. 

When the U.S. government established a branch of its National Asylum for Disabled Volunteer Soldiers (later named National Home for Disabled Volunteer Soldiers) in March 1867, it initially took over the state home in Columbus, but later selected a site in Dayton as its permanent location for the Central Branch home.  Miss Miller became the first matron for the National Homes and brought 16 disabled "boys in blue" with her to the new Dayton site in the fall of 1867.

As matron, she helped at the hospital, oversaw laundry operations, ran the Home's hotel (see photo, left).  Later she was promoted to Superintendent of the General Depot, where much of the clothing and supplies for all of the National Homes was manufactured and distributed. This was a very rare position to held by a woman in those days. In the 1880 National Home’s annual report, she reported that the “Matron’s Department” had washed, pressed, repaired, and reissued over 1,703,648 pieces of laundry and linens, averaging 32,762 pieces per week. Worn out linens were condemned, then washed and reused in the hospital as bandages and dressings, in the engineer’s department as wipers and wrappings for steam-pipes, and as wipers and mops elsewhere.

Emma Miller was about 35 years old when she first became matron for the National Home’s Central Branch in 1867.  When she was appointed as Superintendent of the Depot, effective January 1, 1895, she became an officer on the Board of Managers staff and remained so until her death.  She was a fixture of the Dayton home for nearly 50 years and she lived on-site, like other officers of the National Home.  In 1870 she shared quarters with her three children—Anna (18), Joseph (16), and Henry (13)—and three Irish-born servants.  She spent her entire post-Civil War life at the National Home in Dayton and grew old along with many of the men whom she originally took care of during the war. 

Emma Miller died in her quarters at the National Home on January 18, 1914 after a short illness and, at her request, was buried in the Dayton National Cemetery (formerly the National Home’s cemetery). [photo of headstone, below, Memorial Day 2007]

USING MOTIVATIONAL INTERVIEWING IN PRACTICE

One of the primary acronyms used in MI is O.A.R.S.

This is a brief method of remembering the basic approached to using Motivational Interviewing in practice.  They are sometimes called Micro-Counseling-Skills.

OARS stands for Open Ended Questions, Affirmations, Reflections, and Summaries.

These are:

Open-ended questions:

These are questions that make it difficult for a client to answer with a “Yes” or a “No”.  They also discourage clients from answering a questions with a short, specific, limited piece of information. These questions invite the client into the conversation and help them think about issues more deeply and with more elaboration.  These questions also move the conversation forward and allow the client to explore reasons for change and the different possibilities for change.  Closed-Ended questions have their place in an interview, but they can also stifle communication.

Affirmations:

These are statements that make communication better.  They are statements that allow you to recognize you client’s strengths.  These statements allow you to build rapport with your client and help them see themselves in a different light.  These statements are only effective when they are genuine.  They must be congruent to be effective.  Using an affirmation that does not match the client will often be perceived as superficial. Often clients have tried to change in the past and have been ineffective.  Affirmations allow clients the chance to start again and to feel change is possible.  These statements often reframe behaviors to show the client’s positive qualities.  These are the key element in facilitating MI’s principle of Self-Efficacy.

 Reflections

Of all the skills in MI, reflective listening is probably the most crucial skill.  Reflective listening has two primary and crucial purposes.

Its first purpose is to activate the basic principle of Expressing Empathy. When the therapist provides careful listening and appropriate reflective responses, the client will begin to accept that the therapist understands the issues from their perspective.

Reflective listening also assists in guiding the client toward their change and supporting the client’s goal-directed change.  Reflections assist the client in perceiving their ambivalence and allow them to focus on the negative aspects of the status quo.  It helps them focus on change.

Summaries:

These are a special form of a reflection in which the therapist reviews and recaps what has been discussed and decided in one or more of the counseling sessions.  These reflections communicate interest, understanding and allow the therapist and client to identify the most important elements of the conversation.  Summaries can be used to help the client re-frame and shift their attention in a new direction, thereby preparing them to change and “move on.”  These statements are able to highlight both sides of a client’s ambivalence about change and promote the development of discrepancies that can be selected by the therapist to strategically determine which information needs to be augmented and which information should be minimized.

Change Talk

These are statements are made by the client. They enable to therapist to watch the client as they reveal the clients consideration and motivation and a commitment to change.  The task of the therapist using MI seeks to guide the client to the expressions of change talk.  The therapist is not the Guru.  They are the trail-guide.  Current research shows a clear correlation between client statements about change and the outcomes the client later reports.  These reports show a greater level of success in changing a behavior.  The more your client talks about change; the more likely they are to change.

Different types of change talk can be described using the mnemonic DARN--‐CAT.

 Preparatory Change Talk

      Desire (I want to change)  

        Ability (I can change)

       Reason (It’s important to change)

       Need (I should change) And most predictive of positive outcome:

Implementing Change Talk

       Commitment (I will make changes)

       Activation (I am ready, prepared, willing to change)

        Taking Steps (I am taking specific actions to change)

10 Strategies for Evoking Change Talk

These are the specific therapeutic strategies that are likely to elicit and support change talk in Motivational Interviewing:

1. Ask Evocative Questions: Ask an open question, the answer to which is likely to be change talk.

2. Explore Decisional Balance: Ask for the pros and cons of both changing and staying the same.

3.  Good Things/Not--‐So--‐Good Things:  Ask about the positives and negatives of the target behavior.

4. Ask for Elaboration/Examples: When a change talk theme emerges, ask for more details.

“In what ways?”

“Tell me more?”

“What does that look like?”

“When was the last time that happened?”


5. Look Back: Ask about a time before the target behavior emerged. How were things better, different?

6. Look Forward: Ask what may happen if things continue as they are (status  quo).  Try the miracle question:

If you were 100% successful  in making the changes you want, what would be different?

How would you like your life to be five years from now?  


7. Query Extremes: What are the worst things that might happen if you don’t make this change? What are the best things that might happen if you do make this change?

8. Use Change Rulers:

Ask: “On a scale from 1 to 10, how important is it to you to change [the specific target behavior] where 1 is not at all important, and a 10 is extremely important?

Follow up: “And why are you at ___and not _____ [a lower number than stated]?” “What might happen that could move you from ___ to [a higher number]?”

Alternatively, you could also ask: “How confident are that you could make the change if you decided to do it?”

9. Explore Goals and Values: Ask what the person’s guiding values are. What do they want in life? Using a values card sort activity can be helpful here. Ask how the continuation of target behavior fits in with the person’s goals or values. Does it help realize an important goal or value, interfere with it, or is it irrelevant?

10. Come Alongside: Explicitly side with the negative (status quo) side of ambivalence. “Perhaps _______is so important to you that you won’t give it up, no matter what the cost

Breaking Down MI

 

Part of the beauty of Motivational interviewing is its complex interconnections. Once you begin to understand the basic concepts, you need to integrate the Stage of Changes.

  There are five basic stages of change. These are:

 Precomtemplation

 Contemplation
 Preparation
 Action
 Maintenance

 Relapse (Not really a stage)

Lets’s go through the steps by first defining them; secondly looking at things to consider; third, the therapists tasks, and finally strategies and outcomes.

Definitions

 Precontemplation Defined

People in precontemplation stage have no intention of changing their behavior for the foreseeable future. They are not thinking about changing their behavior, and may not see the behavior as a problem when asked. They certainly do not believe it is as problematic as external observers see it. These individuals are often labeled as "resistant" or in "denial."

 Contemplation Defined

The person is aware a problem exists and seriously considers, action, but has not yet made a commitment to an action.

Preparation Defined

The person is intent upon taking action soon and often report some steps in that direction. Thus, this stage is a combination of behavioral actions and intentions. This is a relatively transitory stage that is characterized by the individual's making a firm commitment to the change process. There may already be some initial steps taken towards change, but even if not, most clients will make a serious attempt at change soon (i.e. one month).

Action Defined

The person is aware a problem exists and actively modifies their behavior, experiences and environment in order to overcome the problem. Commitment is clear and a great deal of effort is expended towards making changes.

 Maintenance Defined

The person has made a sustained change wherein a new pattern of behavior has replaced the old. Behavior is firmly established and threat of relapse becomes less intense.

Relapse Defined

Falling back into old behaviors.

Things to Consider

 
Precontemplation - Things to Consider

Reasons for precontemplation can fit into the "four R's": reluctance, rebellion, resignation, and rationalization. DiClemente (1991) described why these groups do not consider change and methods for intervening.

Contemplation – Things to Consider

This is a paradoxical stage of change. The client is willing to consider the problem and possibility of change, yet ambivalence can make contemplation a chronic condition. Clients are quite open to information and yet wait for the one final piece of information that will compel them to change. It’s almost as they either waits for a magic moment or an irresistible piece of information that will make the decision for them. This is a particularly opportune time for motivational interviewing strategies.

Contemplation and interest in change are not commitment. Information and incentives to change are important elements for assisting contemplators. Personally relevant information can have a strong impact at this stage.

 

Preparation - Things to Consider

Despite making a decision to alter behavior, change is not automatic. Ambivalence, though diminishing, is still present. The decision-making process is still occurring and pros and cons are still being weighed.

 Action – Things to Consider

Action involves a sustained effort at making changes. This period usually lasts from one to six months. Clients have made a plan and have begun implementing it. Ambivalence and commitment are still issues. Too often people do not go back and re-evaluate their change plan. Where is it working? Where did it not? Is there a procedure for re-evaluating the plan? Has there been any planning for handling little slips? Recognize differing levels of readiness to change among issues and the recycling process in the Stages of Change

 Maintenance - Things to consider

Maintenance is often viewed as an afterthought where very little activity occurs. However, maintenance is not a static stage. Relapse is possible and occurs for a variety of reasons. Most relapses are not automatic but occur after an initial slip has occurred. Client’s will often turn to a therapist during what Saul Shiffman calls a relapse crisis (i.e., they’ve slipped or are about to). During these times the client’s self-efficacy is weakened and fear is high. Clients seek reassurance from therapists while trying to make sense of the crisis. Review of the spiral model of the Stages of Change can be very helpful for clients at these times.

Therapist Tasks

 Precontemplation - Therapist Tasks

 • Identify "the problem" - this often means something different for the therapist and the client.

 • Be aware of difference between reason and rationalization. A person, well aware of the risks and problems, may choose to continue the behavior. We may not change them in the face of this informed choice. Our work may have an impact later.
 • Recognize that more is not always better. More intensity will produce fewer results with this group.
 
 Use MI strategies to raise awareness and doubt. Increase the client's perceptions of risks and problems with current behavior.

 • Remember the goal is not to make precontemplators change immediately, but to help move them to contemplation.

 
 Contemplation - Therapist Tasks

 • Consider the pros and cons (from the clients perspective) of the problem behavior, as well as the pros and cons of change.

 • Gather information about past change attempts. Frame these in terms of "some success" rather than change failures."
 • Explore options the client has considered for the change process and offer additional options where indicated and if the client is interested. Remember that our clients are rarely novices to the change process.
 • Elicit change statements.

 Preparation - Therapist Tasks

 • Assess strength of commitment. Strong verbal statements may be a sign of weak commitment. A realistic evaluation of problem area and a calm dedication to making this a top priority are good indicators

 • Examine barriers and elicit solutions (what will the first week be like?)
 • Build coping behaviors
 • Reinforce commitment but provide words of caution where enthusiasm may outdistance actual skills
 
 Action - Therapist Tasks

 Help increase client's self-efficacy by:

 • Focusing on successful activity
 • Reaffirming commitment
 • Making intrinsic attributions for success

 Maintenance - Therapist Tasks

 Therapists do not usually see clients that are well-established in maintenance. If they do, a review of the action plan and a strategy for periodic review of the plan are useful. More often therapists will see clients when a relapse crisis is present. Tasks for these times are:

 • Exploration of the factors precipitating and maintaining the crisis

 • Provision of information
 • Feedback about plans
 • Empathy

Strategies and Outcomes

 Precontemplation - Strategies

 Primary tools are providing information and raising doubt. However, basic skills such as reflective listening, open-ended questions, and functioning as a collaborator (rather than an educator) may be enough. Matching interventions to the type of precontemplators is also helpful.

 Precontemplation - Outcome

 The client begins to consider that a problem or matter of concern exists.

 Contemplation - Strategies

 Inquire about the “good and less good” things of the problem behavior; explore concerns.

 Contemplation - Outcome

 The client is making change statements and makes a tentative commitment to changing the behavior.

 Preparation - Strategies

 Ask a key question. Assist client in building an action plan and removing barriers. Some examples of key questions are:

 • What do you think you will do?

 • What's the next step?
 • It sounds like things can't stay how they are now. What are you going to do?

 One structure for a change includes six elements:

 • Specific statement of changes to be made

 • Why these changes are important
 • Steps in making these changes
 • Inclusion of others in the plan
 • A method for evaluating the plan • Identification of possible barriers to the plan

 Preparation - Outcome

 The client is making clear change statements and has an action plan in place.

 
 Action - Strategies

This stage is familiar to most therapists and involves interventions they have experience in providing

(e.g. skill building, group work, relapse prevention, active problem solving, counter-conditioning, stimulus control, contingency management).

Action - Outcome

Clear changes in behavior are manifested and the risk of relapse diminishes as new behavior patterns replace the old problematic behavior.

Maintenance - Strategies

When crises are occurring, slow the process down. Explore what succeeded, as well as what is precipitating their current concerns or crisis. Offer models of success while normalizing relapse in situations where change is not easily accomplished. If the client is returning to discuss their success, reinforce their active efforts in making change possible and their commitment to change.

Maintenance - Outcome

Client exits the Stage of Change spiral. For a relapsing client, they re-enter the contemplation or preparation stage.

 

Motivational Interviewing Defined.

MI is an evidence-based clinical practice used in the treatment of individuals with substance use disorders.

MI focuses on ambivalence, on exploring and resolving the centers of the motivational processes within the individual in order to facilitate change. It is different from other methods that are viewed as coercive or externally driven as a way of motivating change.

External methods do not appear to have the same success of MI because they impose change that may be inconsistent with the person's values, beliefs or wishes. MI supports a person’s change in a manner that runs parallel to that person's values and concerns.  In fact, the primary spirit of MI is collaborative and puts the client in charge of how, when, and what they want to change.  The therapist is a partner who actively resists the urge to “be the expert” in the client’s change process.

The MI Approach places interviewing in a grounded and respectful stance that focuses on building rapport during the initial stages of the therapeutic relationship.

MI centers on identification, examination, and resolution of ambivalence concerning a person’s changing behavior. Ambivalence, the feeling of wanting to change and wanting to stay the same, at the same time, is seen as a natural issue in the change process and not an aberration.

Using MI allows the interventionist to “tune in to” the person’s ambivalence, therefore allowing the interventionist to recognize ambivalence and “readiness for change.” They are then able to use these strategies thoughtfully with the responsive client.  The interventionist listens for “change talk” and helps the client be aware of his own ambivalence.

 Get more Clinical Information...

MI includes three essential elements.

First it is a specific type of conversation about the change a client wants to and needs to embrace.

Second, it is a collaborative effort that places the client at the center and honors the autonomy of the client. It assumes the client is the expert and supports the client in bringing forth their expertise.

Finally, MI seeks to call forth the client’s own motivation and commitment. It evocates client change by evoking internal responses. It is internally driven, not externally forced.

To the non-professional MI is a collaborative conversation used to strengthen the client’s own motivation to change.

For the professional, MI is a person-centered counseling method which allows the client to address their common, acknowledged issues and their internal ambivalence regarding the need to change.

MI is a collaborative, goal directed method of communication between the interventionist and the client, with a very specific focus on the “language of change.”  It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change.

MI is more than just a set of technical interventions. It is an intervention set with a spirit. This “spirit”, or “way of being” involves the technical aspects of MI as they play out in the context of the client-therapist relationship. One cannot be divorced from the other.

The SPIRIT of MI can be understood if you can visualize the intervention resting on three, very specific elements. They are:

1)      Collaboration between the client and therapist

2)      Drawing out the client’s ideas for change
3)      Placing the emphasis for change on the client. (punctuation)

•        Collaboration (vs. Confrontation)

Collaboration is a partnership formed between the therapist and the client, grounded in the point of view and experiences of the client. This partnership removes the therapist from the “expert role” and keeps the therapist from imposing their perspective on the client’s substance use patterns.

This collaboration allows the building of rapport and allows the client to develop a deep level of trust in the relationship. It keeps the relationship on a more unilateral level, instead of a hierarchical relationship.

 It is important to remember this collaboration does not mean the therapist and the client will agree on the problem, its scope or its solution. The MI therapeutic process is focused on mutual understanding.

·         Evocation (Drawing Out, Rather Than Imposing Ideas)

MI values the therapist’s ability to assist the client and “draw out” their ideas, opinions, thoughts and feelings, instead of having the therapist impose their desires, opinions and motivations on the client.  Like water drawn from a well, the client’s motivations to change are already there, the MI therapist merely helps the client bring them to the surface.

Change due to internal motivation and commitment is more powerful and durable than change related to external motivation (such as someone else saying you should or have to do something).  MI purports that lasting change is more likely to occur when the clients discover their own reasons and determination to change.  With MI the therapist's job is not to tell them what to do or why they should do it.

·         Autonomy (vs. Authority)                 

MI understands that the true power for change rests within the client.

Ultimately, it is the individual who needs to follow through and make change happen.

This allows empowerment while also allowing the responsibility to rest squarely on the client’s shoulders.  Sometimes, client’s simply are not ready to change yet.

In MI, the therapist job is also to help the client understand there is no one "right way" to change, but there are many ways that change can occur.

 
While clients are encouraged to make changes, they are also encouraged to develop a list or “menu” of various options and how to achieve and implement these options.

In addition to the three pillars of on which rests the “Spirit of MI” there are FOUR distinct principles that guide the practice of MI.

 

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The FOUR Principles of MI

In order to use MI appropriately, you, the therapist must adhere to these principles.

• Express Empathy

Empathy requires the therapist see the world through the eyes of the client. This includes thinking about things the way the client thinks and feeling things like the client feels them.

This principle allows for clients to be heard and understood, and in turn, it is more likely the clients will share their experiences honestly. If the client is able to feel the therapist can see their world from their point of view, the process of EMPATHY has been effective.

• Support Self‐Efficacy

MI is a strength-based approach, based on the idea clients have the capacity to change within themselves. They simple need assistance accessing this ability. In order for change to occur the client must be able to believe in the possibility of change. The therapist role is to help instill the hope necessary for the changes to occur. This belief in an ability to change is called self-efficacy.

This is not always an easy task, as clients have often tried to change in the past and have failed; now doubting their abilities. The MI therapist will always support this self-efficacy through focus on previous success and client skill and strength.

• Roll with Resistance (aka: Dancing with Discord)

MI therapists believe that resistance to change comes from previous unsuccessful changes and where a client perceives a conflict between their view of the “problem” or “solution” and the clinician’s view of the “problem” or “solution”. This conflict violates the freedom and autonomy of the client that results in frustration in failure.

The MI therapist will avoid creating or eliciting resistance. Avoiding confrontation does this when resistance occurs. The therapist will de-escalate the situation and avoid a negative interaction. This is known as “rolling with it.”

When the client demonstrates actions or makes statements that demonstrate resistance, these should remain unchallenged by the MI therapist during the early stages of the therapeutic relationship.

When the therapist “rolls with the resistance” they disrupt any “struggle” that can occur during the session. This lack of resistance keeps the client from avoiding change by playing the games of "devil's advocate" or “yes, but” when the counselor makes suggestions.  MI places a high value on the client’s ability to define the problem and to develop his or her own solutions. This approach makes it difficult for the client to resist change.

When exploring the client’s concerns, the therapist invites the client to examine a new point of view without presenting the therapist’s point of view. Finally, the therapist needs to avoid the tendency to make sure the client understands and agrees with the need to change. This is known as the “righting reflex.”  Therapists want to help their clients and may try to “fix” things by directing clients to the “right way” to solve their problems. The MI therapist avoids using this “righting reflex” at all times during a session.

• Develop Discrepancy

This occurs when the therapist is able to help the client see the mismatch between “where they are and where they want to be.” This awareness creates the motivation to change. The MI therapist helps the client develop this by helping them examine the discrepancies between their current circumstances/behavior and their values and future goals.

Once the client realizes their current behaviors place them in conflict with either their values or goals, they are more likely to increase their motivation to make the changes they need in order to reduce the conflict.

The MI therapist should never use strategies that create conflict and discrepancy. They should help the client slowly become aware of the discrepancy between their behavior and their progress towards their current goals.

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Harvey Norris, MSW, LCSW

Harvey Norris received his MSW from Florida State University in 1990 and passed the license exam in 1993.  Harvey Norris, his wife  and five children live in Central Louisiana where he continues to practice "The Worlds Best Profession!"