This document provides an overview of a workshop on motivational interviewing (MI) given by Michael Fulop. The key points are:
- Michael Fulop is a psychologist who provides ongoing training on MI skills to diabetes educators.
- His agenda includes discussing the evidence for MI in psychotherapy, showing examples of MI in practice, and having attendees practice MI skills through role plays and discussions.
- MI is a collaborative communication style aimed at strengthening a person's own motivation and commitment to change. It is not a way to trick people into doing what they don't want or a standalone therapy, but can be used to enhance other treatments.
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AASE ODE MI Workshop 5.23.12
1. Motivational Interviewing
“A work in progress…”
AADE/ODE MI Workshop Series
Michael Fulop, Psy.D.
Clinical & Consulting Psychology
FORSTER FULOP
Rewarding Diabetes
2. What’s one specific MI take-away
you might use in your practice?
michael@rewardingdiabetes.com
4. My Agenda
Provide ongoing training to AADE/ODE
providers to improve MI skills
Discuss evidence for MI in psychotherapy
Show examples of MI in practice
Have you practice MI – in your setting
How comfortable role/real playing? 0-10
How comfortable taping self in practice? 0-10
Humble + Curious
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michael@rewardingdiabetes.com
5. What would like to accomplish
today?
•30 seconds
•Your Name
•Where do you practice?
•What’s one specific take-
away from today, imagine
what it might be.
•Write down as we go along
michael@rewardingdiabetes.com
6. MI Publications
Last Count was ~754, RCT’s > 180
michael@rewardingdiabetes.com
7. Some Things MI is Not
MI not Transtheoretical Model - MI not intended as a
comprehensive theory of change
MI does not trick people into doing what don’t want to do
★ Not an end run for outwitting people
★ MI is “with” or “for” someone, not “to” or “on”
MI is not what you already are doing
★ Near zero-correlation for perceived competence in MI –
★ Attending 1 workshop doesn’t improve outcomes for clients
★ Practice is needed, being coded, being observed and practice
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michael@rewardingdiabetes.com
8. Some Things MI is Not
MI is simple, but not easy
Not easy to integrate complex skills
Like learning to play a musical instrument!
MI is not a Panacea
It’s a specific way to address the need to make
behavioral changes when someone is ambivalent
★ People ready for change do not need MI
Mi is not stand-alone therapy – adds
effectiveness w/other treatments w/1- 4 sessions
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michael@rewardingdiabetes.com
10. What MI is…
After 30 years of research we
have a treatment approach
that is evidence-based [over
200 RCT’s published], relatively
brief [typically 1-3
sessions], that can be
specified, grounded in testable
theory, with identifiable
methods of action, verifiable as
to when it is being delivered
competently, generalizable
across a wide range of
problem areas, complimentary
to other treatment
methods, and learnable by a
wide range of providers – WR
Miller, Ph.D.
michael@rewardingdiabetes.com
11. Recent definition of MI - MI-3
MI is a collaborative, goal-oriented style of
communication with particular attention to the
language of change, designed to strengthen
personal motivation for & commitment to a
specific goal by eliciting and exploring the
person’s own reasons for change within an
atmosphere of acceptance and compassion.
Miller & Rollnick, 2011
michael@rewardingdiabetes.com
15. Evidence For MI efficacy
Dunn, C, Deroo, L, Rivara, F (2001) The Use of brief interventions adapted from
MI across behavioral domains. Addiction, 96; 1725-42.
Burke B, Arkowitz H, Dunn C (2002) The efficacy of MI and it’s adaptations:
What we know so far. In Miller & Rollnick [eds] Motivational Interviewing, 2nd
[2002]
Burke B, Arkowitz H, Menchola M (2003) The efficacy of MI: A meta-analysis of
controlled clinical trials. Journal of Consulting & Clinical Psych, 71 843-61.
Britt, E, Hudson S, Blampied N (2004) MI in health care settings: A review.
Patient Education and Counseling, 52, 147-55.
Rubak, S, Sandboek A, Lauritzen T, Christensen B (2005) MI: A systematic
review and meta-analysis. British Journal of General Practice, 55, 305-12.
Hettema J, Steele J, Miller W (2005) Motivational Interviewing.
Annual Review of Clinical Psychology, 1 91-111.
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michael@rewardingdiabetes.com
16. Further Study - Resources
Rosengren, D.B. (2009). Building Motivational
Interviewing Skills: A Practitioner’s Workbook. New York:
Guilford Press.
Arkowitz, H. Westra, H. Miller, W.R., & Rollnick, S. (2008).
Motivational Interviewing in the Treatment of
Psychological Problems. Guilford: New York.
Miller, W.R., & Rollnick, S. (2002). Motivational
Interviewing: Preparing People for Change. Guilford:.
Training Tapes: MI Series
MI Website: www.motivationalinterview.org
michael@rewardingdiabetes.com
19. MI Spirit
Collaborative
Honors client expertise and perspective
Creates an environment that supports change
Evocative
Resources lie within client
Enhance their intrinsic motivation
less about external pressure
Promotes Client Autonomy
“Patient is right” they have capacity for self change
Facilitate informed choice
Compassion - MI-3 [Miller & Rollnick, 2012]
michael@rewardingdiabetes.com
20. Miller Conversation on the Spirit of MI
Interview for Psych1
michael@rewardingdiabetes.com
21. What is MI Spirit?
1-5 Ranking
Evocation
Collaboration
Autonomy/Support
Spirit = [EV] + __ [CL] + __ [A/S]/3 = ___
Evocation + Collaboration + Autonomy/Support/3]
Direction
Empathy
michael@rewardingdiabetes.com
22. A Continuum of Styles
Directing <=> Guiding <=> Following
Behavior therapy
Cognitive therapy
Reality therapy
Dr. Phil
Motivational interviewing
Solution-focused therapy
Psychodynamic
Psychotherapy
Client Centered
Psychotherapy
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michael@rewardingdiabetes.com
23. • It’s MI when…
• The communication style
involves person-
centered, empathic listening
(engaging), and
• There is a target of change
and that is the focus of
conversation (focusing), and
• The interviewer evokes a
person’s own motivation &
reasons for change
(evoking), but
• It may or may not include
planning.
michael@rewardingdiabetes.com
25. These 4 processes are somewhat linear
….
Engaging necessarily comes first
Focusing (identifying a change goal) is a
prerequisite for Evoking
Planning is logically a later step
Engage Focus Evoke Plan
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michael@rewardingdiabetes.com
26. . . . . and yet also recursive
Engaging skills [& re-engaging] continue
throughout MI
Focusing is not just a one-time event;
re-focusing often needed; focus may change
Evoking begins very early in encounters
“Testing waters” with planning may indicate
a need for more of the above
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michael@rewardingdiabetes.com
27. Ambivalence
Feeling 2 ways about change is common &
normal
MI accepts ambivalence; patient gets time to
explore & consider both sides of their dilemma
Telling people why they should change evokes
the “righting reflex” & increases resistance
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michael@rewardingdiabetes.com
29. Ambivalence
Occurs throughout the change process
Reflects costs and benefits of change and status quo
Is uncomfortable & may become chronic
Resolved by client – Bem’s Self-Perception Theory
What people say to themselves, is what they believe
michael@rewardingdiabetes.com
32. Ambivalence under
pressure…
Leads to discord
Tends to elicit push back
Predicts worse outcomes
Is something we avoid in MI
michael@rewardingdiabetes.com
33. Reinforcing Change
Statements
Be attentive
Don’t have to respond immediately
May collect like a bouquet of flowers
Warning – be attentive to ambivalence
michael@rewardingdiabetes.com
34. Pair Up - 1 speaker & 1 listener
• Speaker talks about a change they are ambivalent
about – they want to change, but have not
started yet [real play, or role play patient].
Speaker begins, describes change they want.
• Listener your job is to convince your speaker
about why they should change – list your
reasons, why you think they should change
• 4 minutes – then we debrief
• What happened to you as the person who wants
a change? What’s it like?
• What happens to you, the listener/”convincer”
What’s it like?
michael@rewardingdiabetes.com
35. Installing Motivation?
• Speaker discuss a change you want to make – or play a
client, patient
• Listener – Your task is to help this person come hell or
high water
• Instead of listening, please:
• Explain why s/he should make this change
• Give 3 specific benefits of making the change
• Tell him/her how to change
• Emphasize importance of the change
• Tell the participant to do it!
• Don’t use MI!
michael@rewardingdiabetes.com
36. Evoking Motivation?
• Speaker continue discussing change
• Listen carefully - goal to understand their dilemma
• Ask these four questions:
• Why would you want to make this change?
• How might you go about it, in order to succeed?
• What are the 3 best reasons to do it?
• On a scale of 0-10, how important would you say it is to
make this change?
• And why are you a ? and not zero?
michael@rewardingdiabetes.com
38. OARS
Open Ended questions
Strength based questions
Affirmations
Reflective Listening
Summarizing
michael@rewardingdiabetes.com
39. Engaging a real individual
• Remember, you are not their 1st provider
• May need to overcome some barriers –
• My 1st Q -“Have you seen any other mh providers?”
• Relationship building is needed
• Accepting ambivalence is particularly important
• Don’t insist on diagnosis acceptance
• Target problems and client goals – not diagnoses
michael@rewardingdiabetes.com
40. Exercise: On the Nature of
Helpfulness
Imagine a major pressing dilemma in your life
Professional or Personal
Debating this with yourself
Imagine
Your thinking is moving in ever tightening circles
You’re in a state of perplexity
It’s affecting all aspects of your life
You’re making little progress on your own
So… you decide to seek out help
Activity from Jeff Allison
michael@rewardingdiabetes.com
41. Exercise: The Nature of Helpfulness
Who should you discuss this with?
Don’t want to make a mistake - Choosing wrong
person leads you in wrong way
Go to Powell’s, grab some coffee and sort this out
What are desirable qualities & skills of such a
person? How would you want them to behave?
Make two lists by yourself
Most desirable qualities & skills
What will make you feel antagonistic and or
disappointed?
This Exercise is from Jeff Allison
michael@rewardingdiabetes.com
43. MI GOAL
Change Talk
michael@rewardingdiabetes.com
44. Change Talk
Change talk is any client speech that favors movement in the
direction of change
Previously called “self-motivational statements” (Miller &
Rollnick, 1991)
Change talk is by definition linked to a particular behavior
change goal
DARN CATs
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michael@rewardingdiabetes.com
45. Preparatory Change Talk
DARN Examples
DESIRE to change (want, like to, wish.,)
ABILITYto change (can, could . . )
REASONS to change (if . . then)
NEED to change (need, have to, got to . .)
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michael@rewardingdiabetes.com
47. Mobilizing Language
Three Types: Commitment, Activation & Taking Steps
I an done with being depressed.
I am ready to do something different.
My boyfriend said I didn’t need my meds, but I told him I
did.
michael@rewardingdiabetes.com
48. Is mobilizing language enough?
Some Answers…
I wish I could…
I’d like to…
I think I should…
I could if I really wanted to…
I have good reasons to…
For some questions...
Do you swear to tell the truth, whole truth and…?
Do you take this person to have and to hold in sickness in
health…?
michael@rewardingdiabetes.com
49. Responding to Change Talk
All EARS
E: Elaborating: Asking for elaboration, more detail, in what
ways, an example, etc.
A: Affirming – commenting positively on the person’s
statement
R: Reflecting, continuing the paragraph, etc.
S: Summarizing – collecting bouquets of change talk
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michael@rewardingdiabetes.com
50. Sustain Talk
The other side of ambivalence
I really like marijuana (Desire)
I don’t see how I could give up pot (Ability)
I have to smoke to be creative (Reason)
I don’t think I need to quit (Need)
I’m gonnna keep smoking (Committment)
I’m not ready to quit (Activation)
I went back to smoking this week (Taking Steps)
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michael@rewardingdiabetes.com
55. What is Resistance?
Behavior
Interpersonal (It takes two to resist)
A signal of dissonance
Predictive of (non)change
The Righting Reflex - Reactance
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michael@rewardingdiabetes.com
56. Handling Resistance
• Already in skills repertoire
• May not eliminate, but can reduce “heat”
• Three reflective types:
• Simple
• Amplified
• Double-sided
• Two Strategies
• Shifting focus
• Emphasize personal choice
michael@rewardingdiabetes.com
57. Handling Resistance - Reflection
• I thought a little red wine was supposed to be good for your heart.
• I know the meds are good for me, but they make me too drowsy.
• I think you are blowing this way out of proportion, I only got a little
messed up, why are you such a prude?
• You don’t understand what it’s like for me, you’ve got a job and
career; all I got is these memories.
• Meds don’t help much anymore, but something’s got to, or I am out
of here.
• I’ve tried everything you’ve asked. None of that shit works. Why
don’t you get it?
michael@rewardingdiabetes.com
58. Sustain Talk and Resistance
Sustain Talk is about the target behavior
I really don’t want to stop smoking
I have to take pills to make it through the day
Resistance is about your relationship
You can’t make me quit
You don’t understand how hard it is for me
Both are highly responsive to counselor style
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michael@rewardingdiabetes.com
59. Foundational Skills –
Simple, Not Necessarily Easy
• Open Questions
• Affirmations
• Reflective Listening
• Summaries
• Offering Information
michael@rewardingdiabetes.com
60. Asking
Develop an understanding of client’s situation
Allows you to:
Follow a decision tree
Arrive at a diagnosis
Complete forms
Closed questions can be:
Efficient way to gather specific information
May create or reinforce the expert-trap
michael@rewardingdiabetes.com
61. Open-ended Questions
These sets the tone for MI work
Communicates interest and caring
Allows client room to respond
Makes client more a more active partner
You receive information otherwise unavailable
Creates momentum
michael@rewardingdiabetes.com
62. Listening
MI is built on this skill
Directive use of listening
Attend to some things and not others
Create awareness of gaps
Reinforce change talk
michael@rewardingdiabetes.com
63. Effective Listening:
Is not asking
More than paying attention
Is not just silence
More than repeating words
Way of thinking
michael@rewardingdiabetes.com
64. Reflective Listening
2 levels of reflection
Simple - content stays close
Repeating
Rephrasing
Complex – guesses at
unexpressed, affect, anticipates, and
metaphors
Paraphrasing Meaning or Intent
Reflecting Feeling
michael@rewardingdiabetes.com
65. Reflective Listening
Vary your depth
Timing is important
Typically undershoot
michael@rewardingdiabetes.com
66. Exercise – Two Levels of
Reflections
Form groups of 4
Choose a representative to record answers
Record Simple & Depth Reflections for each sentence
stem
michael@rewardingdiabetes.com
67. Being Directional
Not telling client what to do
Choosing to attend to different elements
Usually multiple elements in a statement
Focus will determine path
michael@rewardingdiabetes.com
68. Examples of being directional
I’m tired and it feels impossible right now.
You’re worn out.
It feels really hard to do.
Right now is a problem, but maybe later won’t be.
michael@rewardingdiabetes.com
69. Summaries
Special form of reflective listening
Different kinds:
Collecting – short, continue flow (change talk)
Linking – add recent material to prior info (ambivalence)
Transitional – announces a shift in focus (change
direction)
michael@rewardingdiabetes.com
70. Affirmations
• Some clients are demoralized
• Orients people to their resources
• Be genuine
• Probe partial successes
• Reframe resistance into an affirmation
• What and how questions are helpful
• Use “you” statements, not “I”
michael@rewardingdiabetes.com
71. Informing
Successful communication requires:
Transmission of technical information
Interpersonal skills
Therefore, a relationship is key to good
informing
michael@rewardingdiabetes.com
72. Useful Informing
Ask permission
Offer choices
Use other client examples
Chunk-Check-Chunk
Elicit-Provide-Elicit
michael@rewardingdiabetes.com
73. Useful Informing
Slow down and progress may be quicker
It’s a person not an information receptacle
Consider the client context & priorities
Amount matters and depends on the client
Best method? The individualized one
Beware of righting reflex
michael@rewardingdiabetes.com
74. What’s one specific MI take-away
you might use in your practice?
michael@rewardingdiabetes.com
77. Reflections
Reflections are a way of hypothesis testing without the
questions
They are a way to attune to the person
They are choosing where you think someone might be
going
Heart of MI
michael@rewardingdiabetes.com
78. Reflective Responses
Three levels of Reflections
Repeats - or parrots
Rephrases - with simple word changes
Paraphrasing – infers a meaning
Reflection – of feeling, value, or attitude
Simple
Complex
michael@rewardingdiabetes.com
79. Intensity of Reflections
Understated or attenuating a reflection
“You a slightly annoyed”
Which direction will the client go?
Overstating or Amplified Reflections
You are outraged
Which direction will the client go?
michael@rewardingdiabetes.com
80. “I really hate my boss telling me I have to pick up those
boxes over and over again.”
Understated reflection
Which direction will the client go?
Amplified Reflection
Which direction will the client go?
michael@rewardingdiabetes.com
81. Double Sided
On the one hand you want to … On the other hand you
don’t want to.
You’ve told me some good reasons to stop smoking, and
in some ways you love it a lot
michael@rewardingdiabetes.com
82. “My friends say I should just stop smoking pot, but I am
not sure I can anymore.”
michael@rewardingdiabetes.com
83. “My diabetes used to be easy to control, but I’m not sure
I can get it under control any more.”
michael@rewardingdiabetes.com
84. Practice
“Since my accident, I don’t care if I live or die, and I
wonder if anyone else cares?”
michael@rewardingdiabetes.com
86. Reflection Practice
“It’s fun, but something has to give. I can’t go on
like this anymore.”
“I know I can do some things differently., but if she
would just back off, the this situations would be a
lot less tense. These things wouldn’t happen.
I’ve been depressed lately. I keep trying to get back
to using exercising more, but my back always
hurts, it is so frustrating. A couple of drinks would
help.
michael@rewardingdiabetes.com
87. Reflection Practice
“So I’m not too worried, it’s been over a year, and I
can still walk with that knee pain.”
“I know I should lose some weight, everybody tells
me that, but nobody knows how hard it is for me. I
wish I was on the biggest loser.”
My daughter thinks it’s her body, and so she should
be able to do what she wants. Hooking up is no big
deal to her. She doesn’t get why I won’t back off.”
michael@rewardingdiabetes.com
88. Contact Information
Michael J Fulop, Psy.D.
michael@rewardingdiabetes.com
www.rewardingdiabetes.com
503.539.4932
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michael@rewardingdiabetes.com