Powerpoint accompanying workshop session from the Homeless and Housing Coalition of Kentucky's 2013 conference. Presented by Patrick McKiernan Motivational interviewing is a technique that uses a dialogue between a counselor and a client who needs to change behaviors in his or her life. The purpose of this technique is to be non-confrontational, non-adversarial and non-judgmental, and uses open-ended questions and reflective listening to forge a relationship between counselor and client built on trust and empathy. This session will present basic information on how to help increase motivation to change with individuals considering but uncommitted to change. The discussion will include background, theory, and techniques related to the change process.

1. MOTIVATIONAL INTERVIEWING
GETTING STARTED WITH
MOTIVATIONAL COUNSELING
Patrick McKiernan PhD, CADC
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2. Overall Seminar Goal
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• Provide a quick start to motivational
counseling:
– Focus on practical clinical aspects
– TRY to limit theory and concepts
– Increase ability to implement MI
– Increase practice skills
– Increase supervision/evaluation skills
• Exposure to research that is changing
motivational interviewing practice

3. MI intervention overview (big
picture)
 MI targeted behavior: Create and sustain
engagement in an adherence change
plan.
 Follow Doctor’s recommendations
 Meditational: Different than actual
treatment adherence.
 Key point: MI is behavior specific

4. MI is highly strategic
 Advanced counselors are more strategic…
 Strategic: More efficient (briefer) and effective
 Client state is continually assessed
 Navigational map
 Counselor utterance is a strategic response
 Few client states
 Relatively few MI strategies
 Memorize

5. Influences and References
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 Client Centered Therapy (Carl Rogers): Non
Directional
 Motivational Interviewing (Miller & Rollnick):
Directional Approach
 Self Determination Theory (Deci and Ryan):
Psychological Needs & Quality of Motivation
 Transtheoretical Stages of Change (Prochaska
and DiClemente): Process of change
 Behavioral Economics (newly applied to
change): Time value and temporal effects on
decision making.

6. Rooted in Natural Change
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• Self-actualization tendency (Rogers)
• Adaptive creatures  Systems perspective
– Manipulate environment to meet their needs
and desires
– Opening up a closed system
• Self Determination Theory: Human thriving
– Subtle nature of motivation… behavior doesn’t
follow behavioral principles…
– Better motivation is more value driven

7. RESEARCH ON MI: Meta
Analysis
Important distinction from Hettama (p. 108)
MI does NOT communicate
―I have what you need.‖
BUT RATHER
―You have what you need, and together we
will find it.‖

8. Research on MI:
Works as Standalone or Front End
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 Phase I vs. Phase II
 Before and after commitment to change.
 MI works as a standalone intervention
 As a front end for some other intervention
to increase treatment adherence
Phase I
Motivational
Counseling
Phase II:
Open ended menu of options
Phase I
Motivational
Counseling
Phase II:
Some prescribed treatment
emphasized (e.g., Lincoln Trail)

9. Meta Analysis: Summary
 The evidence base for MI is extremely
strong in addiction and growing in health.
Evidence base is vast ―72 target clinical
trials spanning a range of target problems
(Hettema, 2005)‖
 Current research is focused on finding
―why‖ and ―how‖ it works.
 Research on learning: Best learned
through practice.

10. Meta Analysis
 Works better than alternative approaches with
 with people from ethnic minority groups.
 angry and resistant, or less ready for change
clients.
 MI as preparation for any other treatment program
 High effect sizes are observed
 Improves tx adherence and retention
 The effect endures across time
 When MI is used as a standalone
 rapid impact of MI
 gradual de-crease of effect size across time
 Implications: Booster sessions
 Use as a stepped care program (followup built in)
 Used as fallback (followup built in)

11. What is motivation?
How do we change it?

12. Miller & Rollnick on,
What is motivation?
• Motivation: Mediates MI  tx adherence
• Measurement: Recognition or action
– Ambivalence is difficult to measure
• Complex construct: Not
feeling, thought, behavior;
… rather, a drive / energy / fuel
• Dynamic / volatile across time and
environment
• M&R: Ready (committed), willing
(important), and able (self-efficacy /
confidence)

13. SIMPLE NAVIGATIONAL MAP
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WORKING ALLIANCE
(red)
Importance
of Change
Commitment to Change
Change Plan
?? Temporal Effects ??
Change
Confidence

14. Major influences and
trends
What is MI?

15. Nature of Change Discussion
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 Think of some non-trivial behavioral change that
you or someone you know attempted?
 Smoking, diet / weight, exercise, etc.
 What important values or goals were the impetus
for change?
 Was it self change or aided change? What
helped? What didn’t help? Did education help?
 Describe pattern of change across a long period
of time. Lapse?

16. Application to yourself
1. Think of one change you would like to make in
your life.
2. How ready do you feel to make this change?
3. Use a rating ruler to rate your readiness to
change:
NOT READY TO CHANGE UNSURE READY TO CHANGE TAKING ACTION
1 2 3 4 5 6 7 8 9 10

17. Phase I: Continual assessment
determines strategy (RICC)
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1. Relationship: How strong is my
relationship with this person?
2. Importance: Is change important to
him/her? Is he or she ambivalent?
3. Confidence: How confident are you that you can change if you
tried? Will self efficacy support change plan?
4. Commitment: What do you want to do?
Note: All counselor strategies should be ideally directed at advancing
one of the four RICC components.

18. Therapeutic Relationship (TR or
working alliance) Dilemma
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• Strong TR is related to greater change.
• How will we know the level of TR?
– Will they tell us? Can we ask?
– If they do, can you rely on what they
say?
– Can you judge?
• Can only best be judged through
counselor behaviors.
• Problem: Requires preventive efforts
and hyper vigilance.

19. Therapeutic Relationship (TR)
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 Rogers: Create an environment for self-
actualization TR
 Synonym: Working alliance
 RULE: A TR is a requirement for
facilitating change.
 No TR / No change.
 What are risks to TR?

20. Developing & Maintaining TR
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 Spirit of Motivational Interviewing
 Psychological needs (self-determination
theory)
 Autonomy / internal locus of control
 Challenge / competency / self efficacy
 Relatedness
 All of the MI principles aid in increasing TR
 Express empathy --Support self efficacy
 Understand resistance --Develop
discrepancy

21. TR: Risk and Protective Factors
Supportive / Protective
 Accurate
understanding
(or empathy)
 Client talks>50%
 Support autonomy
 Convey
competency
 Sponsor relatedness
 Affirm and accept
(unconditional positive
regard)
 Understand
resistance
 Discover
goals/values
 Ask permission for risk
factors
Risk factors*
• Observe / confront
• Give advice / fix it
• Educate / fix it
• Share opinion
• Take on authority
role
• Debate / argue /
defend
• Being rushed
• Fail to listen
• INACCURATE
• REFLECTIONS!!!
*Avoid whenever
possible. Ask
permission when
necessary.
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22. Risk created by brevity
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 Poor TR  Blocks chance to help
 Avoid TR risk whenever possible
 Brevity: Need for balance
 Know when you
are taking risk
 Calculate risk
 Mend fences
 Monitor client relationship
 Risk is minimized by asking permission
and tone in which you give
advise, educate, or observe

23. 3 Strategies to improve
importance
1. Assess importance and elicit most important
reasons for change with rulers
2. Use decisional balance exercises to fully
assess, clarify, and organize ambivalence
3. Life plan discovery: Explore past successes
and future plans to achieve important goals
and values (desired or ideal)
• Raises discrepancy

24. Strategies to improve importance
1) Use of the Importance Ruler
 Efficiently assesses importance
 Also discovers most important reasons for
change.
 How: ―On a scale of 1 to 10, how important is
making a change?‖
 If client is high (8 or above) in
importance, summarize and move to assessment of
CONFIDENCE
 If client response is 7 or below, elicit most important
reasons for change with a ruler
 Why would you say a [stated value] compared to
[stated value minus 3 or 4].

25. Strategies to improve importance
2) Decisional Balance Exercises
 Decisional balance Weighted list of pros/cons.
 Aids the client (and the counselor) in clarifying level of
ambivalence vs. importance.
 What are the good things and not so good thinks
about recovery? List them.
 Pros/Benefits/Good things (the pros and change and cons of status
quo)
 Cons/Costs/Not so good things (cons of change and pros of status
quo)
 KEY Response: Reflect the underlying value.
 Every pro or con has an important value/goal attached to it…. OR
THEY WOULDN’T MENTION IT.
 Making that connections increases brings clarity.

26. Transtheoretical
Stages of Change
Prochaska & DiClemente

27. Trans. Stages (process) of Change.
Where does clinical purpose shift?
Stage of Change
 Precontemplative
 Contemplative
 Preparation /
Determination
 Action
 Maintenance
 Relapse
Client Process
 Unaware Pre-crystallization
 Unwilling Discrepancy (conflict with
important goals/values)
 Discouraged Support self efficacy
 Ambivalent Discrepancy tips scale
 Commit & prepare
Collaborate on treatment plan.
 Carryout Tx plan / learn
 Relapse prevention / refine
 Overcome shame / regain confidence
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28. MI 2nd Edition: 2 Phases of Change
1. Uncommitted to change: Resolve ambivalence in two
forms…
 Important? Awareness of value incongruence.
 Confidence? Self-efficacy—will it work? can I do it?
 Phase 2 shift marked by intent / commitment
2. Committed: Collaborate on change plan
 Collaborate / menu of choices for action plan…
 Continue to assess for importance / confidence
 Termination

29. MI Sandwhich
 MI Assessment “sandwich” concept:
 MI strategies during opening 20 mins
 Agency intake assessment
 MI strategies during closing 20 mins

30. MI emphasis on ―spirit‖
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• Open ended question: Begin with how or
what.
• Spirit (SDT research based version):
– Autonomy (emphasize client choice)
– Competency (they have what they need),
– Relatedness (peer relationship, no authority).
• Reflections
– Good: Simple (paraphrase)
– Complex: Reflect emotion or change
meaning

31. DISCOVERY: Achieving 2 Ends
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• Interview for most important goals and
values (ideal life)  Achieves 2 ends
– People crave to be understood
– Initiates the process of raising importance.
• Focus on constructing a vision of the
clients desired (or ideal) life.
– Value clarification
• Spirit: Use TR protective strategies and
avoid TR risks.

32. Discovery: Common
Values/Goals32
 Health
 Money / security
 Relationship with some romantic partner
 Wellbeing of children and family
 Psychological needs (SDT): Autonomy /
competency / relatedness
 Will favor experiences that promote these
 Relatedness: Social support  peer vs.
authority.

33. TR Risk: Nuance
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 Some people are harder than others
 Greater or lesser need for controlling
interaction
 Depressed people are oftentimes preferring
advice and more assertive TR
 Trap: Clients are accustomed to being
treated in an authoritative way.
 Will they complain if you are typical of other
professionals? Normal???
 How will they notice if you are ―different than
other counselors.‖ Will they tell you?

34. Accurate Empathy &
Reflections34
 Empathy is conveyed with reflections
 Statement of understanding
 Simple reflection: Parroting or paraphrasing
 Complex reflection: Changing or adding
meaning or emotion
 Reflections are better than questions…
 Conveys understanding
 Does not cause pause to consider question.
 Keeps conversation on Clients track, not our
own.
 Accelerates the pace of the interview

35. Motivational Interviewing Clinical Interview:
Putting Responsibility for Change on the Patient.
 Simple Reflection
 Shifting Focus
 Reframing
 Rolling with
Resistance
 Siding with the
Negative
 Self-Efficacy
 Avoiding Arguments
 Open-ended
Questions
 Listen Reflectively
 Expressing Empathy
 Develop Discrepancy
 Affirm

36. REFLECTING
ACCURATE
EMPATHY
Ongoing method to
communicate understanding
and stimulate deeper
instropsection
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37. KEY: Management of Self
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 TIMING… Never suggest a planning idea until
Phase II change planning.
 ***Manage YOUR RIGHTING REFLEX
 Hard to observe someone in pain
or suffering without reacting
 Makes us want to fix
 Fix it statements are not good
 Our righting reactions must
be managed!!!
 Impatience and burn out are also sources of
reactionary problems.

38. Myth? Resistance or Denial
 Despite the common belief, researchers
have suggested that there is no
denial, only resistance (caused by
paradox).
 Addicted people are aware of problems
related to drinking.
 People will become resistant in response
to confrontation or emphasizing the
need for change (paradoxical
response).
 It’s not denial it’s resistance caused by paradox

39. Strategies to improve importance
1) Use of the Importance Ruler
 Efficiently assesses importance
 Also discovers most important reasons for
change.
 How: ―On a scale of 1 to 10, how important is
making a change?‖
 If client is high (8 or above) in
importance, summarize and move to assessment of
CONFIDENCE
 If client response is 7 or below, elicit most important
reasons for change with a ruler
 Why would you say a [stated value] compared to
[stated value minus 3 or 4].

40. Strategies to improve importance
2) Decisional Balance Exercises
 Decisional balance Weighted list of pros/cons.
 Aids the client (and the counselor) in clarifying level of
ambivalence vs. importance.
 What are the good things and not so good thinks
about recovery? List them.
 Pros/Benefits/Good things (the pros and change and cons of status
quo)
 Cons/Costs/Not so good things (cons of change and pros of status
quo)
 KEY Response: Reflect the underlying value.
 Every pro or con has an important value/goal attached to it…. OR
THEY WOULDN’T MENTION IT.
 Making that connections increases brings clarity.

41. Strategies to improve importance
3) Life planning discovery
 Clarifies, aids client in healthy life planning
 Protracted dialogue on achieving the desired
(or ideal) life
 Desired life: Goals and values discovered previously
 Explore… how can you achieve the desired life
while continuing to use… look forward, look back.
 Explore… how would it be different if you were to
decide to change your drinking.