Motivational Interviewing

Question 1

Who created Motivational Interviewing

Answer 1

clinical psychologists William Miller and Stephen Rollnick. The concept evolved from their experience of treating problem drinkers, who typically are ambivalent about changing their behavior

Question 2

What is motivational interviewing? How is it different from other methods of motivating change?

Answer 2

“… a collaborative, person-centerd form of guiding to elicit and strengthen motivation for change” or “a collaborative conversation to strengthen a person’s own motivation for and commitment to change.”

Differing from more “coercive” methods for motivating change, motivational interviewing does not impose change, but supports it in a way which is congruent with the person’s own values.

Question 3

What are the essential 3 characteristics of MI?

Answer 3

1) Conversation about change; it is thus counseling, therapy, consultation, and also a method of communication
2) Collaborative, meaning person-centerd, autonomy-honoring, partnership-driven, and not set up as expert-recipient
3) Evocative, seeking to call forth the person’s own motivation and commitment (motivationalinterview.org, n.d.)

Question 4

What is the root of the word ambivalence?

Answer 4

The word ambivalence has two (originally Latin) morphemes, “ambi-” meaning both, and “valent”, from a word referring to vigor or strength (Farlex, 2009). An ambivalent person is one who is pursuing – with strength – both (that is: two opposing) courses of action at the same time.

Question 5

What happens when using direct persuasion to resolve ambivalence?

Answer 5

Client resistance increases and change becomes even less probable.

Question 6

How are client denial and resistance to change seen from an MI perspective?

Answer 6

Not as client qualities, but feedback regarding therapist behavior.

When there is resistance, it is often because the therapist is assuming too much readiness to change on the part of the client. In this case, the therapist needs to back off and modify motivational strategies. Readiness to change, then, is seen to fluctuate as a function of interpersonal interactions rather than being a client trait

Question 7

In which application is MI seen as equal to or superior to treatments like CBT and psychopharmatherapy?

Answer 7

Decreasing alcohol and drug use in adults and adolescents.

Question 8

In which 6 applications is MI shown to be efficacious?

Answer 8

1) Reducing drug and alcohol use
2) Smoking cessation
3) Reducing risky sexual behaviours
4) Increasing adherence to treatment and medication
5) Diabetes management
6) Reduction of substance use in HIV-positive men and women

Question 9

What are some potential applications of MI, not yet supported by clinical trials?

Answer 9

1) Management of the smoking, nutrition, alcohol, and physical activity factors
3) Management of compulsions: problem gambling, hypersexuality, or compulsive spending
4) Management of risky behavior (e.g., unprotected sex, sharing needles)
5) Pain management
7) Overcoming eating disorders
8) Weight management issues
9) Stress management
10) Enhancing parenting practices
11) Completion of recommended screening, diagnostic tests, or referral to specialists/allied health practitioners

Question 10

What are the 5 guiding principles of MI? What is the acronym?

Answer 10

Develop discrepancy
Express empathy
Amplify ambivalence
Roll with resistance
Support self-efficacy

Question 11

John Galbraith once said that, given a choice between changing and proving that it is not necessary most people…

Answer 11

…get busy with the proof.

Question 12

What is the aim of the Develop Discrepancy principle?

Answer 12

To help clients think about the change, away from an unhealthy behaviour or toward more healthy habits. Thinking about this change is uncomfortable if it is highly charged with emotion. Counsellor’s task is to ensure there is a discussion of consequences of both changing and not changing.

Question 13

What are some techniques to develop discrepancy?

Answer 13

1) Scaling questions
2) Decisional matrix (similar to DBT pros and cons)
3) The Columbo approach

Question 14

What are some examples of scaling questions?

Answer 14

“How important do you think it is for you to change right now, on a scale of one to ten?”
“How confident are you, on a scale of one to ten, of being able to change?”
“What would it take for you to be at X (a rating position a little higher than the number the client has given)?”

Question 15

What are the components of a decisional matrix?

Answer 15

A 4 square grid showing benefits and costs of staying the same and changing.

Question 16

What is an example of the Columbo approach?

Answer 16

With the Columbo approach, an interviewer makes a curious enquiry about discrepant behaviors without being judgmental or blaming:

“It sounds like when you started using party drugs there were many positives. Now, however, it sounds like the costs, and your increased used of them, along with your partner’s complaints, have you thinking about quitting. What will your life be like if you do stop?”

Question 17

What are some examples of questions to help Develop Discrepancy?

Answer 17

1) Tell me some good and not so good things about your behavior.
2) How do you think your life would be different if you were not ____ (drinking, smoking, skipping your medication, getting stressed out, etc)?
3) How do you imagine your life to be like if you don’t make changes and continue to ____ (use, gamble, smoke, etc)?
4) How does your _____ (risky behavior) fit in with your goals?
5) On one hand, you say that your _____ are important to you, yet you continue to _____. Help me to understand…
6) What do you feel you need to change to achieve your goals?
7) How will things be for you a year from now if you continue to _____ (have risky or compulsive sex, eat a high fat diet, let your blood sugar get out of control, etc)?
8) Hypothetically speaking, if you were to make a change in any area of your life, what would it be? (Braastad, n.d.)

Question 18

Why is expressing empathy important in MI?

Answer 18

1) When people feel understood, they are more likely to share their experiences with us, which makes us more able to determine where they need information and support.
2) Empathic listening is vital to minimizing resistance and has a major impact on a client’s willingness and capacity to change.
3) High levels of empathy are associated with positive results across a broad range of different therapies

Question 19

What is the MI principle that addresses the ‘stuckness’ clients often feel?

Answer 19

Amplifying Ambivalence.

Ambivalence to change is normal, but MI is as effective a change technique as it is because the “to-ing and fro-ing” between the two poles can paralyze clients, causing them to remain stuck. As you bring the ambivalence out into the open and explore the two sides the client is dealing with, the client is enabled to work through it, opening the door to change.

Question 20

What are some examples of questions that Amplify Ambivalence?

Answer 20

1) How has your behavior been a problem to you? How has it been a problem for others?
2) What was your life like before you started having problems with ____ (compulsive shopping, smoking, drinking, etc)?
3) If you keep heading down the road you’re on, what do you see happening (Braastad, n.d.)?

Question 21

What are examples of resistance talk?

Answer 21

Disagreeing: “Yes, but . . . “
Discounting: “I’ve already tried that”
Interrupting: “But . . .”
Sidetracking: “I know you want to talk about how I fell off the wagon (got drunk) last week, but have you noticed how faithful I’ve been about attending the AA meetings?”
Unwillingness: “You want me to do that as well?”
Blaming: “It’s not my fault. When my partner starts in with . . .”
Arguing: “I don’t care what the research says. How do you know that’s true in my case?”
Challenging: “Well, meditation might work for some people, but it doesn’t help me at all.”
Minimizing: “I’m not that overweight.”
Pessimism: “I keep trying to do better on this, but nothing seems to help.”
Excusing: “I know I should consume less sugar, but with my intense work schedule, there’s no bandwidth left over for micro-managing my food intake.”
Ignoring: (The client turns away or changes topic, ignoring your interventions) (adapted from Latchford, 2010).

Question 22

What is the 4 letter acronym that represents resistance overcome, and what do the letters stand for?

Answer 22

DARN.

Desire
Ability
Reason
Need to change

Question 23

What should therapists avoid when encountering resistance?

Answer 23

The righting reflex: to let them know they are wrong and we are right. Because it feeds an escalating spiral of resistance, to the total detriment of any possible change

Question 24

Why do researcher’s believe that advice giving only works 5-10% of the time?

Answer 24

Most of us do not like being told what to do. Rather, most people prefer being given choice in making decisions, particularly changing behaviors

Question 25

What are 5 aspects/stages to sanctioned advice giving in MI?

Answer 25

1) Ask permission: “If you’re interested, I have a recommendation (idea/suggestion/tidbit) for you to consider. Would you like to hear it?” 2) Offer advice: “Based on my experience, I would encourage you to consider _____” or “From what I have observed, it seems that _____ might be a good option for you.” In cases where the client’s current situation is urgently harmful, you must try to get some action going right away. In this case, you may make a stronger statement: “As your _____ (psychotherapist/social worker/health care professional), I urge you to _____.” “In my best professional opinion, I must urge you to consider _____ now.” 3) Emphasize choice: “Of course, it’s your decision.” “Naturally, it’s up to you.” 4) Elicit response and more change talk: “What do you think about this suggestion?” “How do you think this might fit into your current situation?” 5) Voice confidence: “I feel confident that if you decide to _____, you will find a way to do it” or “I feel certain that if you commit to doing this, you will have the will power to carry it through” (adapted from Berg-Smith, 2001).

Question 26

For whom are paradoxical statements particularly helpful?

Answer 26

Clients who have been coming to treatment for some time with little progress.

Question 27

What are some examples of paradoxical statements that roll with resistance?

Answer 27

1) “Sally, I know you have been coming to these weight management program sessions for two months, but your food diary shows that you are still eating in the way that you were before you began, and you haven’t shed any weight. Perhaps now is not the right time for you to try to lose the weight?” 2) It’s ok if you don’t want to quit; it’s your choice 3) Perhaps this new regime is just too much to adopt all at once 4) Maybe you aren’t ready to quit 5) What do you want to do? How do you want to proceed? 6) Where do you want to go from here? (Braastad, n.d.)

Question 28

What is a tactic to use with a client who does not immediately disagree with a paradoxical statement?

Answer 28

Suggest thinking about what was said between now and the next session. Sometimes the combination of the paradoxical statement with being asked to think about it is enough of an eye-opener for clients

Question 29

What are the risks of using paradoxical statements?

Answer 29

Client may agree and argue against change. Client may be offended if therapist appears to be insincere or sarcastic in expressing the paradox.

Question 30

What are 4 strategies to Support Self-Efficacy?

Answer 30

1) Reframing (more positive, realistic view of success) 2) Enhancing creativity of problem solving (brainstorming) 3) Breaking problem down into manageable steps 4) Eliciting statements of self-motivation

Question 31

What are examples of statements to elicit self-motivation and optimism?

Answer 31

1) “What makes you think that this is a problem?”) or concern (“What is there about your ____ [drinking, spending, gambling, etc] that you or other people might see as reasons for concern?”). 2) You can enquire about intention to change (“If you were totally successful and things worked out perfectly, what would be different?”) 3) Finally, you can elicit optimism through questions such as, “What makes you think that, if you decide to make a change, you can do it?

Question 32

What are some examples of Support Self-Efficacy Statements?

Answer 32

“It seems as though you have put a lot of thought into these goals” “You have a good plan of action” “You indicate that you are still struggling with making these changes, and yet you have had some success at making these things happen” “It sounds like you have made real progress; how does that make you feel?”

Question 33

What is the 4 letter acronym for the basic MI approach to interactions with the client, and what do they stand for?

Answer 33

Open-ended questions Affirmations Reflective Listening Summaries (we don’t often zip along toward a new place of completed change, yet by steady, sustained effort with our OARS, we will eventually get there)

Question 34

What are some reasons for using affirmations with clients?

Answer 34

To build rapport and to change client's perspective that they are failed change-agents.

Question 35

What are four types of reflection in reflective listening?

Answer 35

1) Content reflection 2) Meaning reflection 3) Amplified reflection 4) Double-sided reflection

Question 36

What is content reflection?

Answer 36

You simply feed back to the client the main content of what was said.

Question 37

What is meaning reflection?

Answer 37

You include information that either the client told you in a previous conversation (and which is relevant to the current one) or you reflect emotions which may not have been directly stated, but which you suspect are lying right underneath the surface.

Question 38

What is amplified reflection?

Answer 38

When done right, this form can powerfully lead to a re-appraisal by the client. You exaggerate what the client has just said to the point that the client may disavow or even disagree with it. You must make sure, however, that you do not overdo it, as then the client would feel patronized or mocked, with the likely result of anger. This reflection can be exemplified by: Client: But I can’t quit drinking. It would hardly be possible to attend all the social engagements I have to go to for work and not drink, especially when everyone else is! Therapist: Oh, I see. So you really couldn’t quit because then you’d be too different to fit in with the social circles that are part of your work scene. Client: Well, that would make me visibly different from most others and I wouldn’t really be a core part of things anymore, although they might not care as long as they didn’t feel like I was judging them (adapted from Latchford, 2010; Miller & Rollnick, 1991).

Question 39

What is a double-sided reflection, and what order should the reflection be?

Answer 39

With a double-sided reflection, the therapist/practitioner reflects both the current, resistant statement and a previous contradictory statement that the client has made. On these, there is a strategic trick which can boost their power to move the conversation in a change-oriented direction. Note the examples below. In the first exchange, the therapist responds with a typical order of the two sides of the reflection: Client: I know I need to get on top of my gambling, but I just can’t imagine not going to the casino. Therapist: So, you’re saying that you do see the need to control your gambling, but at the moment, you can’t see yourself doing it? Typically, people respond to the last part of what they have heard, so a predictable response on the part of the client might be something like: “No, not at the moment. It would just be too hard.” Contrast that with the following exchange: Client: I know I need to get on top of my gambling, but I just can’t imagine not going to the casino. Therapist: So, you can’t see yourself changing just yet, but you really do see the need to get control of the gambling? By finishing on the positive side of the double reflection, you are much more likely to get a response like: “Yes, I know it’s important, and I need to do something about it.” Such a response alters the whole tone of the conversation and moves it in a more desirable direction (from the point of view of successful change) (Latchford, 2010; Miller & Rollnick, 1991).

Question 40

What is reframing?

Answer 40

With this MI skill, you invite clients to examine their perceptions in a reorganized form, allowing the client to make novel meaning from what has been said. For example, if a client complains that a partner or loved one has said, “You need to get help to deal with these problems”, the client may be viewing the person as acting like a nag or telling them what to do. You as therapist can reframe this by saying, “This person must care a lot about you to tell you something that he (she) feels is important for you, knowing that you are likely to get angry with him (her).” With specific reference to alcohol and drugs, reframing can be useful in discussing the issue of tolerance. Clients may report that they are especially good at holding their liquor, or may see their substance use as non-problematic because they “don’t really even get high anymore.” This is an opportunity for the therapist to bring up the concept of tolerance; the statement of not getting high gets reframed to the client as not having a built-in warning system to indicate when s/he has “had enough”. Thus, what originally seems to support the client’s belief that there is no problem (e.g., “I can hold my liquor”) now supports instead the idea that there may be a problem (e.g., “I’m at risk for overdoing it without knowing it until it’s too late.”) (Miller & Rollnick, 1991)

Question 41

How should a therapist end a summary?

Answer 41

With an open ended question like "I'm wondering what you make of all that?"

Question 42

What are Prochaska and DiClemente’s 5 Stages of Change?

Answer 42

``` Precontemplation (not ready) Contemplation (getting ready) Preparation-Action (ready) Maintenance (sticking to it) Relapse (normalized and used as learning) ```

Question 43

What mnemonic captures the preparation and action stages of change?

Answer 43

Preparatory: Desire (I want to change) Ability (I can change) Reason (It’s important to change) Need (I should change) Implementing: ``` Commitment (I will make changes) Activation (I am ready, prepared, willing to change) Taking steps (I am taking specific actions to change) (motivationalinterview.org, n.d.) ```

Question 44

What are some strategies for evoking change talk?

Answer 44

Ask evocative questions: that is, open questions, the answers to which are likely to be change talk. Explore decisional balance: ask for the pros and cons of both changing and staying the same. Identify good things/not-so-good things: ask about the positives and negatives of the target behavior. Ask for elaboration/examples: when change talk themes come up, ask for more details. “What does that look like?” “In what ways?” “Tell me more” “When was the last time that happened?” Look back: ask about a time before the target behavior emerged; how were things better or different then? Look forward: ask what could happen if things continue as they are (that is, the status quo is maintained). The miracle question can come in here: “If you were 100 percent successful in making the changes you want, what would be different? How would you like your life to be five years from now?” Ask about extremes: “What are the worst things that might happen if you don’t make this change? What are the best things that might happen if you do make this change?” Use scaling questions: “On a scale from 1 to 10, how important is it to you to change, where 1 is not at all important, and 10 is extremely important?” This can include the follow-up questions of: “Why are you at ___ and not ___ [a lower number than stated]?” And “What might happen that could move you from ___ to [a higher number]?” These questions can/should also be asked with reference to confidence, e.g.: “How confident are you that you could make the change if you decided to?” Explore goals and values: ask what the individual’s guiding values are and what they want in life. Ask how continuing the target behavior fits in with these goals or values. Does it help realize an important goal or value, interfere with it, or is it irrelevant? Come alongside: you can side with the negative (status quo) side of ambivalence, as in: “Perhaps _____ [drinking, using, gambling, etc] is so important to you that you won’t give it up, no matter what the cost” (adapted from motivationalinterview.org., n.d.)

Question 45

What are some forms of listening failures?

Answer 45

Giving (direct) advice, making suggestions, or providing solutions Persuading with logic, arguing, lecturing Moralizing, preaching Shaming, ridiculing, or labeling Interpreting or analyzing Reassuring, sympathizing, or consoling Questioning or probing Withdrawing, distracting, or humoring (Gordon, in Braastad, n.d.)