Motivational Interviewing

Tucker Peck periodically teaches a Motivational Interviewing class that I've considered taking.  Some portion of Miller and Rollnick's textbook is suggested as preparatory reading for the class, so when I discovered that there was a copy at the library I decided to get a better sense of what MI is all about. To my surprise, I read almost the entire thing.  It's a really well organized and interesting presentation of how to, as the subtitle has it, help people change.  

The basic message is quite simple -- the best way to help people change is to listen compassionately to their problems and help them articulate their own reasons for change and their own plan for how to carry it out.  While the message is simple, it still has a counter-intuitive aspect; we often think the best way to help people change is to convince them that their status quo is wrong.  The book argues that this strategy is frequently counterproductive, at least with ingrained behaviors.  The better approach is not for you to tell them the reasons for change, as if the problem were simply a lack of information or an erroneous logic on their part, but to let them tell you why they should change.  If you argue for change, your friend is apt to find themselves arguing the other side of the debate, which just forces them to come up with new and inventive reasons for maintaining the status quo.  Since our own reasons are always the best, this strategy backfires.  Instead, the core of the technique is about selectively affirming and the reflecting back the reasons that a person already has for changing.  Essentially, they end up convincing themselves. 

Saying the message is simple doesn't mean that I think it would be easy to master this type of conversation in practice.  But I certainly expect it to be an interesting challenge to at least try to have the patience, curiosity, and compassion necessary to help friends sort out what they want to do.   

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Intro

1) Motivational interviewing is a collaborative conversation style for strengthening a person's own motivation and commitment to change.  Avoid the righting reflex and let people overcome their ambivalence and persuade themselves to change.

2) Motivational interviewing is a person centered counseling style for addressing the common problem of ambivalence about change.

1. Partnership, Acceptance, Compassion, Evocation (from within the client)
2. Acceptance = absolute worth, accurate empathy, autonomy support, affirmation

3) Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change.  It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion.

1. Four phases -- engaging, focusing, evoking, planning
2. Core skills -- open questions, affirming, reflective listening, summarizing

Engaging

4) Traps that prevent engagement -- assessment (lots of short informational questions), expert, premature focus (what are all the client's issues?), labeling, blaming, chat 

5) Reflective listening is about prompting someone to continue to explore an issue by briefly reflecting back to them a guess about the meaning of what they've already said.  "Continue the paragraph" and don't throw up roadblocks that encourage stopping.

6) Core conversational skills OARS -- open questions, affirming, reflecting, summarizing

7) Encouraging people to explore their core values can highlight the discrepancy between these and their current behavior and motivate a change.

Focusing

8) MI uses a guided style of deciding what to focus on, midway between directing and following.  Sometimes the focus is clear, sometimes it is unclear, and sometimes there are several clear options.

9) It's important not to narrow the focus too soon.  Agenda mapping is a tool for when there are several possible clear areas of focus.  It is a meta-conversation about which areas are mutually considered most important to talk about.  Orienting is a tool for when the focus is unclear.  It surveys the landscape and attempts to fit various puzzle pieces into a coherent narrative.

10) Don't be evil

11) People's difficulty with change is usually not lack of information.  Give information or advice in an elicit-provide-elicit format -- ask if they want or already know the information, provide it in usable chunks, and ask for a response to the information provided.  

Evoking

12) The mix of change talk and sustain talk reflects ambivalence about changing.  There are two levels of change talk

1. Preparatory change talk -- DARN
1. Desire -- want, wish, hope
2. Ability -- can, could
3. Reasons 
4. Need -- must, have to
2. Mobilizing change talk -- CAT
1. Commitment -- will, swear, promise
2. Activation 
3. Taking steps

13) The more change talk, the more change.  The first goal of MI is to evoke change talk.

1. Ask evocative questions that evoke DARN -- the answers to these questions should be change talk.  Don't ask for questions about why change hasn't or can't happen.  
2. Use the importance ruler -- how important is change, and why isn't is LESS important?  The answer should be reasons why change is at least somewhat important.
3.  Querying extremes -- what is the worst outcome of the status quo?  what is the best outcome of change?
4. Looking back and looking forward -- was their a time before the status quo?  can you imagine a different future?
5. Exploring goals and values -- uncover what goals the status quo is inconsistent with.

14) Respond to change talk in a way that evokes more of it by using OARS to produce more DARN CATS

15) Sustain talk is a natural part of ambivalence towards change, but should be responded to strategically so as to evoke more change talk.

1. Reflection  -- straight, amplified (exaggerated), double-sided (cite reasons for change last)
2. Emphasizing autonomy -- people are more likely to choose change when it feels like a choice
3. Reframing, agreeing with a twist -- drawing out other perspectives 
4. Running head start -- when there is no change talk, you can try listing out all the sustain talk to try and bracket it

     Discord is a breakdown of the therapeutic relationship.  Signs of discord are defending, arguing, or disengaging.  It can be reflected, apologized for, the client's autonomy affirmed, or deflected.

16) People are more likely to change if they believe they can.  Hope for and confidence in the ability to change need to be evoked in the same way as motivation for change.

1. Use the confidence ruler -- why do you have non-zero confidence?
2. Identify and affirm character strengths
3. Review past successes 
4. Brainstorming 
5. Reframe past failures as attempts
6. Hypothetical thinking -- imagine a world in which certain roadblocks have been removed

    Respond to hope and confidence talk in a way that strengthens it using OARS

17) If you want to stay neutral and not guide someone towards change, use a decisional balance approach that systematically examines the advantages and disadvantages of both possibilities.

18) If there is no ambivalence and no interest in change, try to instill a sense of discrepancy between a person's actions and their core values.  One technique is to have them imagine another person's perspective or reasons so they can see themselves from outside.  But let people find the contradiction on their own.

Planning

19) Don't begin the planning process until people are ready.  Signs of readiness include:

1. Increased change talk
2. Taking steps
3. Diminished sustain talk
4. Resolve -- often quiet and unstated
5. Envisioning the future state
6. Asking questions about change

Move from evoking to planning with a recapitulation (a long summary of client change talk) and a key open question (what's next?).

20) Change is more likely if the client has a specific plan that they believe will work and that they can accomplish.

1. If there is one clear plan, you can summarize it and troubleshoot it to evoke more mobilizing change talk (CAT)
2. If there are a few clear options you can itemize them and see which the client believes is most likely to work.  Then this reduces to problem 1
3. If there are no obvious options, you may need to brainstorm some to reduce this situation to problem 2

21) Break a plan down into steps and strengthen commitment to each step using the same tools as for the whole plan.  It can help to have the client tell other people of their specific intentions and to create a monitoring system for themselves.