1. Introduction to Motivational
Interviewing and Stages of
Change
…What the Non-Specialist Needs to Know
Pt 2
By Elizabeth Kotkin, MA, LMFT
Program Director
YES Adolescent Skills Center-
Manhattan

2. What makes behavior change so hard?What makes behavior change so hard?
It works for usIt works for us
It often involves multiple behaviorsIt often involves multiple behaviors
 Knowledge about how to change isn’t alwaysKnowledge about how to change isn’t always
enoughenough
People are creatures of habitPeople are creatures of habit
 Health consequences are often delayedHealth consequences are often delayed
Busy lifestyles require us to make time for self careBusy lifestyles require us to make time for self care

3. Motivational Interviewing
“A therapeutic style
intended to help
clinicians work with
patients to address the
patient’s fluctuation
between opposing
behaviors and
thoughts.”
Source: Miller and
Rollnick, Motivational
Interviewing 1991.

4. What Is Motivational
Interviewing?
It is designed to enhance
the client’s own
motivation to change
using strategies that are
empathic and non-
confrontational
It can be defined as a
patient-centered directive
method for enhancing
intrinsic motivation to
change by exploring and
resolving ambivalence.

6. What Do Clients Really Want?
To be accepted

7. • Open-ended questioning
• Affirming
• Reflective listening
• Summarizing
Building Motivation using
OARS (the microskills)

8. Open-Ended Questions
Asking open-ended questions helps you to understand your
clients' point of view and elicits their feelings about a
given topic or situation.
Open-ended questions facilitate dialog; they cannot be
answered with a single word or phrase and do not require
any particular response.

9. Affirm
When it is done sincerely, affirming your
client supports and promotes self-efficacy.

10. Reflective Listening
Listen to both what the person says and to what the
person means
Check out assumptions
Create an environment of empathy (nonjudgmental)
You do not have to agree
Be aware of intonation (statement, not question)

11. Summarizing
Summaries communicate interest, understanding and call
attention to important elements of the discussion
Can be used to highlight both sides of the client’s
ambivalence about change in order to develop
discrepancies
Draw together the client’s own perspective on change by
linking together something the client just said with
something said earlier.

12. Five Principles of
Motivational Interviewing
(What you are actually doing)
1. Expressing empathy
2. Developing discrepancy
3. Avoiding argumentation
4.Roll with the Resistance
5.Supporting Supporting self-
efficacy

13. 1. Express Empathy
•Empathy communicates acceptance, while supporting the process of
change
•Counselor is an ally to participant
•Participant should feel heard
•Seek to build up, rather than tear down
•Skillful reflective listening is fundamental to expressing empathy

14. 2. Develop Discrepancy
Motivation for change is enhanced when clients perceive
differences between their current situation and their hopes
for the future.
When a person says one thing and then in the next
sentence says the opposite. These are signs of
ambivalence.
Developing awareness of consequences helps clients
examine their behavior.
 A discrepancy between present behavior and
important goals motivates change.
 The client should present the arguments for change.

15. Understanding Ambivalence
Working with
ambivalence is key
Ambivalence is normal,
acceptable,
understandable
Attachment to the
behavior is part of
ambivalence
Ambivalence tips back
and forth

16. Using Discrepancy to
Understand Ambivalence
Interventions: Use the following kinds of statements to
help participants understand their ambivalence
– “On the one hand…On the other hand…”
– “So part of you wants…But another part of you
feels…”

17. Double-Sided Reflection
Captures BOTH sides of the ambivalence
(both…..and…….)
Double – sided reflection:
– I think I would feel so much better about myself if
I were in better shape, but it’s so hard to stick to a
workout plan.
– Counselor: On the one hand, trying to work out
consistently is challenging, but on the other hand,
you think your self-esteem would improve if you
lost weight.

18. Other Ways to Explore Ambivalence
How Important Ruler
0 1 2 3 4 5 6 7 8 9 10
Not At All Important Extremely Important
Ask participant: “How important is this change?”
“Why Not Lower?”

19. 3. Avoid Argumentation
•Resistance is signal to change strategies
•Labeling is unnecessary
•Shift perceptions
•Peoples’ attitudes shaped by their words,
not yours

20. Shifting Focus
You can defuse resistance by helping the client
shift focus away from obstacles and barriers.
Focus is shifted towards what is do-able.
This method offers an opportunity to affirm your
client's personal choice regarding the conduct of
his own life.

22. 4. Roll with Resistance
Roll, rather than confront resistance. Confronting
resistance can cause participant to dig in.
Strategies to help resolve resistance:
– Explore pros and cons of change
– Use “Decisional Balance” tool
– New perspectives are invited but not imposed
– The client is a valuable resource for finding solutions to
problems
Continued resistance equals a signal to change our
approach.

23. Simple reflection
The simplest approach to responding to resistance is
with nonresistance, by repeating the patient's
statement in a neutral form.
This acknowledges and validates what the patient
has said and can elicit an opposite response.

24. Decisional Balance

25. Reframe
Acknowledge the validity of the client’s
observation, but offer the possibility of new
meanings for these observations.

26. 5. Support Self-Efficacy
Belief that change is possible is important
motivator
Person is responsible for choosing and
carrying out actions to change
There is hope in the range of alternative
approaches available

27. Harnessing Self-Efficacy:
“I know I can do it!”
The belief in your ability to do something will
mediate whether or not it is tried, how much effort
goes into it, and how long you will persist in your
efforts.
Explore with participant a time when they were
successful at something (i.e. physical activity or
healthy eating.)

28. One Way to Gain Self-Efficacy
is Seeing Others Succeed:
Role Modeling:
– “If they can do it, maybe I can too.”
– Ask, “Who do you know who has been able to
accomplish this?”
Group activities and workshops can
help to inspire and motivate participants.

29. Borrowing Self-Efficacy
Expressing faith in the participant helps
participant have faith in self.
Participants can tap into other’s belief that
they can accomplish their goals.
Ask, “Who in your family thinks you can
do this?”

30. Motivational Interviewing : Putting
Responsibility for Change on the Client.
Simple Reflection
Shifting Focus
Rolling with Resistance
Double-Sided Reflections
Self-Efficacy
Open-ended Questions
Listen Reflectively
Expressing Empathy
Develop Discrepancy
Affirm

31. This third edition of the book, Motivational Interviewing,
deals with changing health-related behaviors in general.
More resources are available at the MINT website,
including training resources and recent research:
http://www.motivationalinterviewing.org/
Motivational
Interviewing,
3rd
Edition.
Miller and Rollnick