Camh ipe 2013 pub

Motivational Interviewing
CAMH Interprofessional Student Education
February 6, 2013

Marilyn Herie PhD, RSW

Confidence Ruler

No Way I am
0 1 2 3 4 5 6 7 8 9 10 Bill Miller

http://www.williamrmiller.net/

A scientist went to visit a famous Zen master.
While the master quietly served tea, the
scientist talked about Zen. The master poured
the visitor's cup to the brim, and then kept
pouring. The scientist watched the
overflowing cup until he could no longer
restrain himself. "It's overfull! No more will go
in!" the scientist blurted. "You are like this
cup," the master replied, "How can I show you
Zen unless you first empty your cup?"

http://users.rider.edu/~suler/zenstory/emptycup.html

http://www.lifehack.org/articles/lifestyle/sentences-that-can-change-your-life.html

Learning Objectives
1. Identify practical strategies to motivate
change
2. Reflect on how you can adapt these
strategies with your clients
3. Set concrete objectives for clinical
practice

Persuasion Exercise
• Choose one person near you to have a
conversation with, and work together
• One will be the speaker, the other will be
a counsellor

Miller & Rollnick, 2013
14

Speaker’s Topic
• Something about yourself that you
want to change
need to change
should change
have been thinking about changing
but you haven’t changed yet
…in other words – something you’re
ambivalent about
15

Counsellor: Find out what change the
person is considering making, and then:
• Explain why the person should make this
change
• Give at least three specific benefits that
would result from making the change
• Tell the person how they could make the change
• Emphasize how important it is to change
• If you meet resistance, repeat the above.

P.S. This is NOT motivational interviewing
16

Listeners:
What were you thinking
or feeling during this
conversation?


Common Reactions to Righting Reflex
• Angry, agitated • Afraid
• Oppositional • Helpless, overwhelmed
• Discounting • Ashamed
• Defensive • Trapped
• Justifying • Disengaged
• Not understood • Not come back – avoid
• Not heard • Uncomfortable
• Procrastinate
18

“Unsolicited advice is the junk
mail of life.” (Bern Williams)

“Advice is what we ask for when
we already know the answer but
wish we didn’t.” (Erica Jong)

A taste of Motivational Interviewing
21

A Taste of Motivational Interviewing:
Conversation with one speaker and one listener.

Speaker’s Topic:
• Something about yourself that you
want to change
need to change
should change
have been thinking about changing
but you haven’t changed yet
i.e. – something you’re ambivalent about
22

Listener
• Listen carefully with a goal of understanding the dilemma
• Give no advice.
• Ask these four open questions and listen with interest:
1. Why would you want to make this change?
2. How might you go about it, in order to succeed?
3. What are the three best reasons to do it?
4. On a scale from 0 to 10, how important would you
say it is for you to make this change?
Follow-up: And why are you at __ and not zero?
• Give a short summary/reflection of the speaker’s
motivations for change
• Then ask: “So what do you think you’ll do?” and
just listen
23

Speakers:
What were you thinking
or feeling during this
conversation?


Common Human Reactions to
Being Listened to
• Understood • Safe
• Want to talk more • Empowered
• Liking the counselor • Hopeful
• Open • Comfortable
• Accepted • Interested
• Respected • Want to come back
• Engaged • Cooperative
• Able to change
Would you rather work with these people…
Miller & Rollnick, 2013 25

…or these?

Common Reactions to Righting Reflex
• Angry, agitated • Afraid
• Oppositional • Helpless, overwhelmed
• Discounting • Ashamed
• Defensive • Trapped
• Justifying • Disengaged
• Not understood • Not come back – avoid
• Not heard • Uncomfortable
• Procrastinate
26

What is it for?
Motivational interviewing is a
collaborative conversation to
strengthen a person’s own
motivation for and commitment to
change

“I try to get my daughter to eat
healthy, but that food is
expensive and she doesn’t like
it anyway.”

“Injecting Oxycodone isn’t so
great for my veins, but it’s
better than a lot of other crap
out there.”

“I only have unprotected sex
with my boyfriend, and I know
he wouldn’t cheat on me.”

It is your choice But giving your kids
whether to make healthy food is very
this change… important in preventing
future problems

You are the one But if you keep
who has to injecting, your veins
decide… aren’t the only serious
thing to worry about

Regardless of what But even people we
you do, I will be trust make mistakes
here to support sometimes, and that
you… includes your
boyfriend

It is your choice But giving your kids
whether to make healthy food is very
this change… important in preventing
future problems
You are the one But if you keep
who has to injecting, your veins
decide… aren’t the only serious
thing to worry about
Regardless of what
you do, I will be But even people we
here to support trust make mistakes
you… sometimes, and that
includes your
boyfriend

• “It is your choice whether to make this
change.”
• “You are the one who has to decide.”
• “Regardless of what you do, I will be
here to support you.”

“People are most able to
change when they feel
free not to.”
- Carl Rogers

The “Spirit” of Motivational
Interviewing

• Partnership • Absolute worth
• Accurate empathy
• Acceptance
• Autonomy support
• Compassion • Affirmation
• Evocation
41

Partnership

“You are the best judge of what is
going to work for you.”

Acceptance

“I am here to help whatever you decide to do.”

Compassion
Guide me to be a patient companion,
to listen with a heart as open as the
sky. Grant me vision to see through
his eyes, and eager ears to hear his
story…Let me honour and respect his
choosing of his own path.

Adapted from Miller, 2013, “A Meditative Preparation” (p.24)

Evocation

“What were you hoping for by coming here
today?”

Why would I use it?
Motivational interviewing is a person-
centered counseling method for
addressing the common problem of
ambivalence about change.


Where am I in MI?
“Spirit” of MI – Resist the Righting Reflex

0 1 2 3 4 5 6 7 8 9 10

“Spirit” of MI – Directional (versus directive)

0 1 2 3 4 5 6 7 8 9 10

“Spirit” of MI – Evoke (versus educate)

0 1 2 3 4 5 6 7 8 9 10

The Evidence Base for
Motivational Interviewing

Research publications evaluating MI
effectiveness have been doubling every
three years.

www.motivationalinterview.org

MI Outcome Studies by Era
100
80
60
40
20
0
1988-94 1995-99 2000-02 2003-06

Alcohol Drugs Dual Dx Gambling
Offenders Eating Dis Adh/Retention Smoking
HIV Risk Cardiac Diabetes Psychiatric
Health Prom Family Violence Asthma
Dental
Slide from Bill Miller, 2010 55

MI Applications
• Public health & • Medication adherence
workplace • Diabetes
• Sexual health • Mental health
• Dietary change • Addictions
• Weight management • Fibromyalgia
• Voice therapy • Chronic leg ulceration
• Gambling • Self-care
• Physical activity • Criminal justice
• Stroke rehab • Vascular risk
• Chronic pain • Domestic violence

Anstiss, 2009

A Causal Chain for MI

Therapist MI-
consistent speech

Increased client
change talk

Improved treatment
outcomes
Moyers et al., 2009

“What [practitioners]
reflect, they will hear
more of.”
Moyers et al., 2009

“Miller and Mount, 2001 have
suggested that learning MI involves
at least two processes, one of
adding preferred behaviors, and
another of suppression of non-
preferred behaviors.”
(Baer, 2004)

“There is some evidence that
eliminating those responses such as
confrontations, advice without
permission, directing, threatening,
and raising concern without
permission is more important than
just adding MI-consistent responses.”
(Moyers and Ernst, 2001)

But what if the person refuses to
change?

A 'No' uttered from the deepest
conviction is better than a 'Yes'
merely uttered to please, or
worse, to avoid trouble.
Mahatma Gandhi

“He that complies against his will
is of the same opinion still.”
Samuel Butler
1612-1680
English Poet

The Ineffective Practitioner
“Sal”
http://www.youtube.com/watch?v=kN7T-cmb_l0&feature=related

Four Processes in MI
1. Engaging: The relational foundation
2. Focusing: Clarify directions: What is the
horizon?
3. Evoking: The person’s own arguments for
change
4. Planning: Developing commitment to
change + formulating a plan of action

“Planning is the clutch that engages
the engine of change talk” (p.30)
Miller and Rollnick, 2013

Four Processes in MI

Planning
Evoking
Focusing
Engaging

Adapted from Miller and Rollnick, 2013, p. 26

Agenda-Mapping Worksheet
Priorities
Diagnosis Treatment
Plan

Benefits

Symptoms

Agenda-Mapping Worksheet
Priorities
Diagnosis Finances Treatment
Plan

Benefits Stress

Symptoms Relationship

Video Demonstration

Agenda Mapping conversation with "Sal"
http://www.youtube.com/watch?v=klnHJ4coG8o

“Readiness Ruler”
People usually have several things they would like to change in their lives – this may be only one of those
things. Answer the following two questions with respect to your goal for this week.

• How important is it to change this
behaviour?

0 1 2 3 4 5 6 7 8 9 10

• How confident are you that you could
make this change?

0 1 2 3 4 5 6 7 8 9 10

The Effective Practitioner
“Sal”
http://www.youtube.com/watch?v=-RXy8Li3ZaE&feature=related

Change Talk and Sustain Talk
Opposite Sides of a Coin

Sustain Talk and Resistance
• Sustain Talk is about the target behavior
• Resistance is about your relationship
• Both are highly responsive to counsellor
style
• We respond to both in the same way

Change Talk: Sustain Talk:
I should But beer is
really cut good!
back on the
drinking…

Smoking is But it is part
unhealthy… of who we are

I should But I am
practice this booked back-
motivational to-back with
interviewing clients and
stuff… there is no
time!

DARN CAT
• Desire • Commitment
• Ability • Action
• Reasons • Taking Steps
• Need

Yet another metaphor
MI Hill
k M
al ob
Nange
T ili C
R Ch
zin
g A
Aory Ch
an
T
D rat ge
Ta
e pa lk
Pr
(Pre-) Contemplation Preparation Action

Slide from Bill Miller, 2010

DARN CAT

• Need Snap fingers = DARN
Clap = CAT
Silence = No change talk

Listening for Change Talk

“I am getting too old for this
lifestyle.”

• Need

“My probation order is the only
reason I am coming here.”

• Need

“I am not addicted. I can quit
anytime I want.”

• Need

“I want to get well again, but my
pain is still really bad.”

• Need

“I have started a modified exercise
program, quit smoking and drinking,
am practicing mindfulness meditation
for one hour daily and will do whatever
else I need to return to work.”
• Need

When you are not sure where to
go next…

“Tell me more…Tell me more…”

Where am I in MI?

Recognizing Change Talk

0 1 2 3 4 5 6 7 8 9 10

Evoking Change Talk

0 1 2 3 4 5 6 7 8 9 10

FOUR KEY STRATEGIES – OARS
OPEN questions (to elicit client change talk)
AFFIRM the client appropriately (support, emphasize
personal control)
REFLECT (try for complex reflections)
SUMMARIZE ambivalence, offer double-sided
reflection


Mylopoulos, M, Lohfeld, L, Norman, GR, Dhaliwell, G, Eva, KW (2012). Renowned physicians' perceptions of
expert diagnostic practice, Acad Med. 87(10):1413-7.

Mylopoulos, M, Lohfeld, L, Norman, GR, Dhaliwell, G, Eva, KW (2012). Renowned
physicians' perceptions of expert diagnostic practice, Acad Med. 87(10):1413-
7.

“To Listen”

EAR
EYES
UNDIVIDED
ATTENTION

IMPERIAL HEART

Simple Reflection

Complex Reflection

“I’m only coming to group today because my doctor and my
probation officer are both pressuring me.”

Simple Reflection
They are really on your case
about coming to a support
group.

It wasn’t your idea to come
to group, and you’re not
sure this is going to be at all
helpful to you.

Complex Reflection

Practicing Reflective
Listening
Individually, take a moment to write
down an example of a simple and a
complex reflection for the following
statement (coming up – next slide).
Then compare what you wrote with
others at your table. As a group,
choose the best examples to share with
the larger group.

Practicing Reflective Listening (1)
“How I live my life is no
one else’s business, and
certainly not yours!”

“How I live my life is my own business and
certainly not yours.”

Simple Reflection:
___________________________________
___________________________________

Complex (Enhanced) Reflection:
___________________________________
___________________________________

“How I live my life is my own business and
certainly not yours.”

Simple Reflection:
You are the only one to decide how to
live your life.

You’re being told you have to make all
these changes, and that doesn’t feel very
respectful of your choice and autonomy.

Practicing Reflective Listening (2)

“I know you mean well, but
I don’t need this
medication any more.”

“I know you mean well, but I don’t need this

Simple Reflection:
___________________________________
___________________________________

___________________________________
___________________________________

“I know you mean well, but I don’t need this

Simple Reflection:
You see that I am concerned, but you are
ready to stop taking the medication.

You feel like I am pushing for you to take
this medication, and not really
appreciating where you are at.

1. Four volunteers:
Counsellors

2. One volunteer: Client
Something you are considering
changing and struggling with

3. One volunteer: Coach
A sounding board for the client

Reflecting Panel Instructions
1. Client: Share a paragraph with the Reflecting
Panel about your struggle/experience
2. Panel: Take turns offering a single reflection
3. Client: After ALL Panel members are done,
talk to your coach about which reflection
resonates most for you and why
4. Client: Offer this feedback to the panel, and
continue the paragraph

“A Psychological Law”

I learn what I believe
as I hear myself speak.

Bill Miller (Based on D. Bem, 1967, “Self-Perception: An
alternative interpretation of cognitive dissonance
phenomena”)

…or put another way…

The word you keep between
your lips is your slave. The
word you speak is your
master.
- Arabic proverb

Where am I in MI?

Simple Reflections

0 1 2 3 4 5 6 7 8 9 10

Complex Reflections

0 1 2 3 4 5 6 7 8 9 10

Additional Reflections
and Next Steps

Castles in the air?

If you have built castles in the air, your
work need not be lost. That is where
they should be. Now put the
foundation under them.
Henry David Thoreau

Motivational Interviewing: Practice Tips
MI Spirit: The Essential Foundation
Four MI Processes
Partnership: You and the client are equal
experts Planning
Acceptance: Absolute worth, accurate Evoking
empathy, autonomy support, affirmation
Compassion: Beneficence, caring, focus on the Focusing
other
Evocation: The client’s wisdom is most Engaging
important

Agenda‐Mapping OARS: Key Skills
Can we take a few minutes to talk about the different issues or
Listen for Change Talk: DARN CAT
Open  Questions: What are your reasons for
concerns that you or others have? Just to get a “big picture” view  of change? How might you go about it in order to Desire, Ability, Reasons, Need
what you are coping with right now… succeed?
Commitment, Activation, Taking Steps
Affirmation: You have worked hard to make this
Treatment happen. I can see that you’ve given this a lot of
Diagnosis Finances thought.
Plan Readiness Ruler
Reflections: You wish that… You would like to…
Summary Statements: Let me make sure I People usually have multiple or competing priorities. On a
understand how this all fits together… scale of zero‐to‐ten, how important is it to change…? How
confident are you that you could make this change?
Benefits Stress

Elicit: What do you already know about…?
Provide information: Be brief! 0 1 2 3 4 5 6 7 8 9 10

Symptoms Relationship Elicit: How does that fit for you? What do
you make of that? Why did you say [lower number] and not [higher number]?
What would it take to go from [lower number] to [higher number]?

Given  all of these possible areas for change, what are your priorities?
Where would be the most helpful place for us to start? © 2013 Marilyn Herie, PhD RSW       marilyn.herie@utoronto.ca
Reference: Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd Edition). New York: Guilford.

Life can only be understood backwards, but it
must be lived forwards.
‐Kierkegaard

Recommended Resources
Martino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C., Hamilton,
J., and Hausotter, W. (2006). Motivational Interviewing Assessment: Supervisory Tools for
Enhancing Proficiency (MIA STEP). Salem, OR: Northwest Frontier Addiction Technology
Transfer Center, Oregon Health and Science University.
http://www.motivationalinterview.org/Documents//MIA-STEP.pdf
Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (Third
Edition). New York: Guilford.
Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural
and Cognitive Psychotherapy, 37, 129-140.
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416
Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping
Patients Change Behavior. New York: The Guildford Press.
First chapter and table of contents available at www.motivationalinterview.org
Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. New
York: Guilford.
Wagner, C.C. & Ingersoll, K.S. (2013). Motivational Interviewing in Groups. New York: Guilford

Useful Websites
Motivational Interviewing Website
http://www.motivationalinterview.net/
Motivational Interviewing Network of Trainers (MINT) Website
www.motivationalinterviewing.org
Examples of Motivational Interviewing Videos on YouTube
http://www.youtube.com/user/teachproject#p/u

Motivational Interviewing Glossary of Acronyms
Compiled by Marilyn Herie, PhD, RSW November, 2012
ACE (Spirit of MI from Miller and Rollnick 2002 edition)
Autonomy / Collaboration / Evocation versus
Authority / Coercion / Education
OARS (Fundamental strategies of MI)
Open questions / Affirmations / Reflections / Summary statements
EARS (Strategies for eliciting change talk)
Evocation / Affirmation / Reflective listening / Summary statements
RULE (Fundamental strategies in MI v.2)
Resist the righting reflex / Understand reasons for change (motivation) / Listen empathically / Empower
the client to use own resources
DARN CAT (Types of preparatory change talk and commitment language)
Desire / Ability / Reasons / Need / Commitment / Action / Taking steps
FRAMES (Ingredients of brief, motivational interventions)
Feedback / Responsibility / Advice / Menu (of strategies)/ Empathy / Self-efficacy
RAISE (How to give advice)
Relationship / Advice to change / “I” statements (affirmation) / Support autonomy / Empathy
READS (Principles of MI)
Roll with resistance / Express empathy / Avoid argumentation / Develop discrepancy / Support self-
efficacy
PACE (Spirit of MI from Miller and Rollnick 2013 edition)
Partnership / Acceptance / Compassion / Evocation
MIST (Coding form)
Motivational Interviewing Supervision and Training Scale
MITI (Coding form)
Motivational Interviewing Treatment Integrity Coding Form
MET (Manual-based motivational intervention)
Motivational Enhancement Therapy
MIA (Coding abbreviation, used in the MITI)
Motivational Interviewing Adherent
MINA (Coding abbreviation, used in the MITI)
Motivational Interviewing Non-Adherent
MIA-STEP (MI supervision manual and coding resource)
Motivational Interviewing Assessment – Supervisory Tools for Enhancing Proficiency
AMI
Adaptations of Motivational Interviewing

Thank
you

marilyn.herie@utoronto.ca

www.educateria.com

@MarilynHerie

Camh ipe 2013 pub

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