Motivational interview

Fundamentals of Motivational Interviewing

Fundamentals of Motivational Interviewing

Tips and Strategies for Addressing Common Clinical Challenges

JULIE A. SCHUMACHER MICHAEL B. MADSON

1

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Library of Congress Cataloging-in-Publication Data
Schumacher, Julie A.
Fundamentals of motivational interviewing : tips and strategies for addressing common clinical challenges / Julie A. Schumacher, Michael B. Madson.

pages cm
ISBN 978-0-19-935463-4 (paperback)
1. Interviewing—Psychological aspects. psychiatry. I. Madson, Michael B. II. BF637.I5S38 2015
158.3′9—dc23
2014022206

2. Motivation (Psychology) Title.

3. Interviewing in

987654321
Printed in the United States of America on acid-free paper

With gratitude to Scott, Liam, and Levi who support and inspire me every day. —JAS

To Carol and Dave Madson, my colleagues, collaborators, and students. —MBM

Acknowledgments ix
PARTI. MotivationalInterviewingOverview

1. Introduction 3
2. Foundational Concepts and Skills 11 3. e Four Processes of MI 42

PART II. Motivational Interviewing for Clinical Challenges

4. Less Ready to Change 71
Clinical Challenge 1: No-Shows 72
Clinical Challenge 2: Non-adherence 80
Clinical Challenge 3: Client Involved in the Legal System 89

5. Loss of Momentum 99
Clinical Challenge 1: Slow Progress 100
Clinical Challenge 2: Lapses and Relapses 107
Clinical Challenge 3: Overly Ambitious Expectations 116

6. Psychiatric Symptoms and Disorders 124
Clinical Challenge 1: Depression 125
Clinical Challenge 2: Anxiety, Trauma-Related, and Obsessive
Compulsive Disorders 140
Clinical Challenge 3: Psychotic Symptoms 153

7. Working with Multiple Individuals 166 Clinical Challenge 1: Parents 166 Clinical Challenge 2: Groups 173

8. Challenges in Learning to Use and Implement MI 188 Training Challenge 1: Clients who Frustrate You 191 Training Challenge 2: Clients Like You 195 Conclusions 200

References 203
About the Authors 214 Index 215

CONTENTS

ACKNOWLEDGMENTS

We are forever grateful to Drs. Bill Miller and Steve Rollnick for their commit- ment to the ongoing evolution of MI and their altruistic generosity for shar- ing their knowledge with others. eir dedication to MI guides us all! We are thankful to be a part of the Motivational Interviewing Network of Trainers— MINT—and value the energy and discussions about MI among its members. As researchers, we are honored to have colleagues in the international MI research community who advance our knowledge of the application of MI through their critical evaluations. It is through the work of these researchers that the understanding of MI and evidence of its e ectiveness have been generated. We are grateful to these individuals. In particular, we are thankful to have great research collaborators—Drs. Scott Co ey and Claire Lane as well as numerous students and fellows we have had the privilege of mentoring over the years. Our appreciation of MI has developed through the various trainings we have pro- vided, clients we have treated, and cases we have supervised. We are thankful to the students, community providers, and clients who helped us deepen our knowledge of how to practice and teach MI! It is through our experiences with each of these individuals and groups that our ability and inspiration to write this book developed. Finally, we want to acknowledge Margo Villarosa for her careful review of this book.

PART I

Motivational Interviewing Overview

1

Introduction

As described more fully in chapter 2 of this book, motivational interviewing, or MI, is a communication style that providers can use to help facilitate client change. If you are new to motivational interviewing and have just begun reading Fundamentals of Motivational Interviewing: Tips and Strategies for Addressing Common Clinical Challenges, you are probably asking yourself two key ques- tions: (1) “Does MI work?”; and 2) “How do I learn MI?” Whether you are a nov- ice or experienced provider of MI, you are probably asking yourself, “How will this book be helpful to me?” Here we provide answers to these vital questions about MI and outline the key features of this book, its intended audience, and how to use what you learn.

DOES MOTIVATIONAL INTERVIEWING WORK?

Although initially developed and written about by Dr. William R. Miller as an intervention for alcohol use disorders (1983), in the more than 30 years since the original article on MI was published, MI has been applied successfully to promote positive change in areas ranging from reducing problem drink- ing (Vasilaki, Hosier, & Cox, 2006), to weight loss (Armstrong et al., 2011), to reducing criminal o enses (McMurran, 2009), to utilization of life-saving clean water technologies in Zambia ( evos, Quick, & Yanduli, 2000). To say research on MI has been burgeoning may be an understatement. Lundahl and Burke (2009) reported that entering the term “motivational interviewing” into a sin- gle research database (PsycInfo) in March 2009 resulted in the retrieval of 707 articles published during the decade from 2000 to 2009! Although the potential uses of MI are seemingly boundless, it is important that all providers who wish to use MI are aware of the current evidence supporting (and in some cases fail- ing to support) various applications of MI.

At least four comprehensive reviews of the MI literature using a statisti- cal approach called meta-analysis have been published in the last decade (e.g., Burke, Arkowitz, & Menchola, 2003; Hettema, Steele, & Miller, 2005; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Rubak, Sandbaek, Lauritzen, & Christensen, 2005). ese reviews have statistically combined the ndings

4 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

of numerous randomized controlled trials to draw more robust conclusions about the e cacy of MI than can be gleaned from a single study. overall, these meta-analyses suggest fairly unequivocal support for MI as an intervention for alcohol and drug problems, especially when compared to things like a wait list, reading materials, or non-speci c treatment-as-usual. For these problems, MI is generally equivalent but not superior to other speci c interventions, although in some cases MI may require a smaller dose of treatment to achieve comparable e ects (Lundahl & Burke, 2009). ese researchers also found emerging support for MI for improved general health behaviors (e.g., diet and exercise) and health indices (e.g., cholesterol, blood pressure, body mass), gambling, parenting prac- tices, and safe water use. Support was not found for MI improving emotional/ psychological well-being, eating problems, and HBA1c (an indicator of diabetes control), though it is important to note that research to date on eating prob- lems and HBA1c is very limited. Mixed support was found for MI as an interven- tion for HIV risk behaviors and cigarette smoking in the general meta-analyses. However, recent systematic reviews and meta-analyses focused just on smok- ing cessation (Heckman, egleston, & Ho man, 2010; Hettema & Hendricks, 2011) provide stronger evidence that MI can be e cacious for smoking cessation.

Importantly, while MI research literature is burgeoning, there are several promising areas of research on MI that are still in their infancy. is is especially important to note, given ongoing anecdotal evidence we receive as MI trainers, that MI may be utilized most broadly in some of the areas for which it has the most limited support. Four such areas are corrections, group therapy, mental health, and high school counseling. Although MI is widely used in corrections, a recent review of the literature suggests research supporting this application of MI remains limited (McMurran, 2009). Likewise, although many facilities and providers prefer group treatment approaches and o er MI as a group interven- tion, there is far less research on MI as a group intervention, and the research that has been conducted suggests that outcomes are not as strong for group-delivered MI (Lundahl & Burke, 2009; Wagner & Ingersoll, 2013). ere is also increas- ing discussion of how MI might be applied in mental health settings to perhaps enhance treatment engagement and augment outcomes for cognitive behavioral therapy for problems such as depression and anxiety (Arkowitz, Westra, Miller, & Rollnick, 2008; Westra, 2012). In support of those discussions, Lundahl et al. (2010) found promising evidence that MI impacts non-speci c treatment fac- tors, including increasing treatment engagement, increasing client intention to change, and reducing client distress. However, as Burke (2011) notes, there is currently insu cient research to support the de nitive conclusions that inte- gration of MI with cognitive behavioral treatments does in fact improve mental health outcomes. Finally, whereas there is compelling evidence for the e cacy of MI for adolescent substance use and health behaviors (Jensen et al., 2011; naar-King & Suarez, 2011), there is little research that MI enhances achievement or reduces the dropout rate among high school students. nonetheless, there is increasing discussion of the promise MI holds for enhancing school achieve- ment and engagement (Atkinson & Woods, 2003; Frey et al., 2011). given that

Introduction 5

ndings for MI are always emerging and sometimes surprising, providers of MI are encouraged to stay apprised of the MI literature to ensure that it is applied where it is useful and avoided where it is not.

HOW DO I LEARN MI?

given its broad applicability, it is not surprising that individuals from many professional disciplines including, but not limited to, nurses, dieticians, physi- cians, counselors, social workers, psychologists, addiction professionals, pro- bation o cers, clergy, battered women’s advocates, and laypeople have sought to learn MI so they can be instrumental in helping others make positive changes in their lives (Madson, Loignon, & Lane, 2009; Soderlund, Madson, Rubak, & nilsen, 2011). e good news is that although individuals from dif- ferent professional backgrounds may encounter unique challenges in trying to learn MI (Schumacher, Madson, & nilsen, 2014) there is evidence that indi- viduals from a variety of backgrounds and professions can achieve equal out- comes when delivering MI (Barwick, Bennett, Johnson, Mcgowan, & Moore, 2012; Lundahl et al., 2010).

Despite its increasing popularity across disciplines, there is also a mounting body of research to indicate that MI is not “practice as usual” nor is it “easy to learn” (Miller & Rollnick, 2009). our combined 21 years’ experience learning MI, training countless others from varying backgrounds in MI, and doing research on MI training is consistent with those conclusions. Although MI sounds famil- iar and intuitive to many professionals and laypersons alike, for many the prac- tice of MI seems to run directly counter to the strategies commonly relied upon when helping others discuss important life changes. In fact, what seems to come most naturally to many we train (and to us, for that matter!) are strategies that are actually inconsistent with the practices and principles of MI. For example quickly giving advice when someone mentions a problem they are having (e.g., asking, “Why don’t you try . . . ?” or “Have you tried . . . ?”) or directly confronting other’s statements that do not support change we view as necessary or important for them (even when such confrontations are well-intentioned, as in the case of telling someone who says “I just can’t do it”—“Yes, you can!”).

e amount and type of training necessary to achieve provider pro – ciency in MI is both uncertain and more extensive than commonly believed. Although workshops are the most common continuing education model, research suggests that skill improvements are o en not achieved or short-lived with such training (Walters, Matson, Baer, & Ziedonis, 2005) and may be par- ticularly limited when training is urged or required by an employer (Miller & Mount, 2001) rather than independently sought by the trainee (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). Miller and colleagues (2004) found that for highly motivated providers (i.e., providers who self-selected and made expenditures for training) with high levels of baseline skill: (1) 2-day work- shop training alone produces substantial but non-enduring skill increases;

6 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

(2) small doses of both feedback and coaching help maintain training gains; and (3) the combination of feedback and coaching is required to produce desired changes in client utterances during MI sessions. Close examination of the ndings of Miller et al. (2004) study suggests that a combination of training, feedback, and coaching was su cient for most, but not all, providers to achieve and maintain beginning pro ciency in MI, but that few providers achieved expert competence in MI. Anyone familiar with the general litera- ture on becoming an expert will not be surprised by that nding; becoming an expert at anything generally requires copious amounts of supervised practice (ericsson & Charness, 1994). Importantly, Moyers et al. (2008) built on this study by examining the training model with providers who had fewer basic counseling skills and expressed less motivation to learn MI. ey found that for this group only 4.3% to 10.3% of participants met all beginning pro ciency criteria, many training gains eroded by 4-month follow-up, and personalized feedback and consultation did not enhance outcomes. A study examining live-supervision revealed similarly that ve post-workshop supervision ses- sions were insu cient for many providers to achieve pro ciency (Smith et al., 2007; Smith et al. 2012).

In our own work, similar ndings have emerged. We have found that extended and accelerated training approaches that incorporated experiential learn- ing activities (e.g., skill practice and real play practice sessions) have resulted in achievement of beginning MI pro ciency by many participants (Madson, Schumacher, noble, & Bonnell, 2013). However, participants rarely achieved the expert level a er this training. In contrast, when we received and coded par- ticipant work samples and provided feedback and coaching, more participants approached or reached expert level (Schumacher, Madson, & norquist, 2011; Schumacher, Williams, Burke, epler, & Simon, 2013). Anecdotally, we observed that it was in these coaching sessions that participants developed a deeper understanding of MI, its foundational spirit, and how to apply the techniques and strategies in an MI-consistent fashion.

us, the research is very clear that despite the broad appeal and seem- ing intuitiveness of the approach, development of skill in MI rarely occurs in the absence of formal training and coaching. Moreover, development of true expertise in this approach requires a he y dose of training and coaching for most—even those who already have substantial experience in counseling or psychotherapy (Schumacher et al., 2013). us, in the interest of complete transparency, we would like to state directly that we do not believe that read- ing this book and applying the suggested principles and skills on their own are likely to make anyone an expert at MI. MI is a very powerful communi- cation style and therapeutic approach that involves more than simply apply- ing a particular technique to a particular situation (Miller & Rollnick, 2009). nevertheless, interventions that involve the selective application of principles and practices of MI may help improve outcomes, as in the case of screening and brief intervention for alcohol problems in the emergency department (D’onofrio & Degutis, 2002).

Introduction 7

WHAT DOES THIS BOOK OFFER?

Fundamentals of Motivational Interviewing: Tips and Strategies for Addressing Common Clinical Challenges evolved out of our years of experience: (1) con- ducting MI sessions with clients; (2) developing, implementing, and research- ing novel applications of MI (e.g., Madson, Bullock-Yowell, Speed, & Hodges, 2008; Schumacher, Co ey, et al., 2011; Zoellner et al., 2011); (3) surveying expert MI trainers and reviewing the literature about how people learn MI, which aspects of MI they nd most di cult to learn or implement, and which methods facilitate learning (Madson, Lane, & noble; 2012; Madson, Loignon, & Lane, 2009; Schumacher et al., 2012; Schumacher, Madson, & nilsen, 2014; Soderlund et al., 2011); (4) providing training and coaching in MI to countless study therapists, undergraduate and graduate students, addictions counsel- ors, nurses, mental health professionals, allied health professionals, medical students and physicians, probation o cers, and lay volunteers (e.g., Madson, Landry, Molaison, Schumacher, & Yadrick, in press; Madson et al., 2013; Madson, Speed, Bullock-Yowell, & nicholson, 2011; Schumacher, Madson, & norquist, 2011; Schumacher et al., 2013); and (5) developing and evaluating methods to assess MI competency and facilitate coaching (Madson, Campbell, Barrett, Brondino, & Melchert, 2005; Madson & Campbell, 2006; Madson et al., 2013). e book was written with the highly pragmatic reader in mind; the reader who hopes to read all or even portions of this book and come away with not only knowledge about MI, but an ability to apply the principles and concepts of MI to their daily work.

e book is organized into two sections: Motivational Interviewing overview (Chapters 1–3) and Motivational Interviewing for Clinical Challenges (Chapters 4–8).

Since the publication of the original article on MI by Miller in 1983 and the original MI text by Miller and Rollnick in 1991, MI has evolved and changed (Miller & Rollnick, 2002; Miller & Rollnick, 2013). Although the essential ele- ments remain unchanged, de nitions, emphases, and terminology have shi ed over time as researchers uncover more about how and why MI helps individuals change (Miller & Rose, 2009) and how providers learn MI (Miller and Moyers, 2006). us, chapters 2 and 3 of this book are designed to provide the reader with a clear, concise, and current description of foundational principles, prac- tices, and processes of MI. In addition, these chapters illustrate key concepts with vignettes and examples depicting MI-consistent, somewhat MI-consistent, and MI-inconsistent interactions from a variety of settings (e.g., healthcare, sub- stance abuse treatment, criminal justice, and mental health).

e chapters in this book on how to apply MI to various clinical challenges (chapters 4 through 7) evolved primarily out of our years of experience as MI trainers with varied audiences. Time and time again, individuals we’ve trained and coached in MI have asked for guidance in applying the practices, princi- ples, and processes we are teaching them to various speci c clinical challenges. Although the speci cs of the challenging situations in which those we’ve trained

8 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

have sought to apply MI vary greatly depending on the setting within which a particular provider works, their underlying questions are very similar. Questions such as: “How do I use MI to involve someone more actively in creating a treatment plan?” or, “What do you do when a client tries to get you to do all the work for them?” or,“How do you help someone who won’t comply with treatment?” When we address these questions with our training audiences and in chapters 4 through 7 of this book, many times the answers are simple: “You might try agenda setting or elicit–provide–elicit to help engage the client at the beginning of the session.” other times the answers are more complex, and may require the provider to change not only what they say and do with the client but also how they fundamentally think about the client. our goal is to provide you with clear advice and suggestions about how concepts, principles, and skills from MI can be applied to the most di cult situations you encounter in your work.

Chapter 4 addresses how practices and principles of MI can be applied to the challenge of clients who are Less Ready to Change. In particular, we focus on the nearly ubiquitous problems of no-shows and non-adherence, as well as spe- cial considerations and strategies to enhance engagement of clients involved in the legal system. e last section may be of interest even to readers who do not work with legally involved clients, as many clients feel coerced to change by loved ones, employers, or others in much the same way that legally involved clients do. Chapter 5 delves into the challenges associated with Loss of Momentum. In this chapter we discuss how MI can be applied to clients who experience slow prog- ress or setbacks (i.e., lapses or relapses), as well as clients with overly ambitious expectations about how quickly change will progress.

Although chapter 6 focuses on Psychiatric Symptoms and Disorders, speci – cally depressive, anxiety, trauma- and stressor-related, obsessive compulsive and related disorders, and psychotic disorders, this chapter may be of great interest to non–mental health providers— rst, because psychiatric disorders are highly prevalent, and thus clients who are experiencing these symptoms and disorders are likely to present in every setting where MI might be utilized; and second, many of the challenges related to these symptoms and disorders such as poor concentra- tion, disorganized thinking, and lack of motivation are also commonly observed in individuals who do not su er from these symptoms or disorders. In the nal chapter of the section on clinical challenges, chapter 7, we address how practices and principles of MI can be used to address challenges commonly encountered when Working with Multiple Individuals, speci cally parents and groups.

In chapter 8 we provide a series of tips and strategies for learning MI that we have identi ed over our years as MI trainers. We also describe two challenges we have identi ed that seem to impede MI learning and implementation for many providers—namely, feelings of frustration with di cult clients and assumptions that what worked for the provider personally (when they stopped smoking, quit drinking, lost weight, went straight, etc.) is also the best solution for their client. As noted, there is no “quick x” solution for learning MI, but we have found that following some of the tips and tactics and targeting the challenges outlined in chapter 8 may facilitate learning and implementation of MI for some providers.

Introduction 9

FOR WHOM IS THIS BOOK INTENDED?

is book is intended as a resource for individuals interested in applying the principles and practices of MI to their work (paid or volunteer), helping to guide others in making positive changes in their lives. It is intended as a resource for those who are already expert in MI, those who are learning MI, and those who have no prior training in MI, including students. ose who are already expert in MI may nd the updated review of MI practices, principles, and processes in chapters 2 and 3 to be an e cient way to get up to speed on newer concepts and terms. experts may also identify applications of concepts and skills to com- mon clinical challenges (chapters 4–7) that they had not previously considered in their own work. Individuals with some prior MI training may nd the concise and e cient review of key concepts and practical guidance on how to apply the skills and concepts to common clinical challenges a useful complement to their other MI training materials. e MI novice will likely nd this book a useful, easy-to-read introduction to what MI is and how it can be used to improve clini- cal practice and clinical outcomes across a variety of domains and situations. Although for those desiring to achieve expert competence in MI, this book is not intended as a substitute for formal MI training and coaching, even those without such a foundation will likely nd practical and easy-to-implement strat- egies to common clinical challenges in (chapters 4–7). ese chapters may also serve as a nice complement to the information presented in the most recent edi- tion of Motivational Interviewing: Helping People Change, 3rd edition (Miller & Rollnick, 2013) or to formal workshop training in MI.

Importantly, across various professional disciplines and even within these disciplines across various settings, di erent terminology is used to refer to the population being served and the individuals who serve them. However, given the similarities we’ve noted in working with providers across disciplines and settings, we have elected to rely primarily on standardized terminology in this book. Any time we use the term “client” in this book, we are referring to the individuals who will receive a motivational interview. Any time we use the term “provider” in this book, we are referring to YoU. Whatever your speci c job or role within your organization or agency (whether paid or volunteer), odds are you have a part to play in helping the individuals you serve make positive changes in their lives. Although many speci c examples of applications of MI concepts and strategies will be super cially applicable to a particular setting or population, all examples were selected and written to illustrate concepts that are relevant to most or all MI providers. Readers are encouraged to read all exam- ples, not simply those that depict interactions that might commonly occur in their work setting.

As noted by Miller and Rollnick (2013), MI is a compassionate approach that puts the needs of others above self. us this book is not intended for use by individuals who seek to use its principles and practices to promote their own self-interest or manipulate others. Depending on the context in which a provider works and his or her relationship to clients within that context, the provider’s

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ability to place the best interests of the client ahead of self-interest or agency interest can be more di cult to navigate. In our discussion in chapter 4 of how MI principles and practices can be applied to clients with legal involvement, we provide further discussion and guidance on how providers can compassionately apply the principles of MI in cases where the client is being o ered or required to participate in services he or she did not seek. As a nal note, although many of the professionals and volunteers we have trained who are also parents or spouses have reported that using re ective listening and asking open questions (which are not unique to MI) have improved communication in their personal relation- ships, MI is not intended for use in personal relationships with spouses, children, or friends.

HOW TO USE THIS BOOK

Whereas MI-novice readers may choose to read this book from cover to cover, experienced MI practitioners may choose to read only a few relevant chapters. Whether you have thoroughly read none, one, a few, or all of the chapters in this book, we have designed the book to be useful as a quick reference. When you encounter a particular clinical challenge or feel stuck, we encourage you to ip to the table of contents of this book and read those chapters or sections most relevant to the challenge you face. For example, if you have a client who has started to miss appointments and you suspect it may be because he or she has anxiety about coming to see you, you might choose to read the section in chapter 4 on no-shows and the section in chapter 6 on anxiety. However you choose to use this book, we hope you will nd it a helpful guide in how to apply the practices and principles of MI to help resolve a number of ubiqui- tous clinical challenges.

2

Foundational Concepts and Skills

WHAT IS MOTIVATIONAL INTERVIEWING?

Motivational interviewing (MI) was initially described as a counseling approach based on methods from Carl Rogers’s person-centered therapy and social-psychological principles such as cognitive dissonance and self-e cacy to help increase client motivation to change problem drinking behavior (Miller, 1983). However, over the past 30 years, the de nition has become broader and is applicable to a range of professional disciplines and target populations. In 2009, Miller and Rollnick rede ned MI as “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change” (Miller & Rollnick, 2009, p. 137). Miller and Rollnick (2013) recently expanded on this de nition to pro- vide a more comprehensive understanding of what MI is for, how it works, and why you may want to use it. Miller and Rollnick’s (2013) expansion includes:

What is MI for? MI is a conversation between individuals, o en a provider and a client, about change. Rather than telling clients what to do, the MI-consistent provider would collaborate with them in an attempt to strengthen their personal motivation for change.

Why should you use MI? An MI-consistent conversation focuses on clients’ motivations for change and in particular feelings of ambivalence they have about changing. Although ambivalence about change is commonly experienced, failure to address such ambivalence can keep a person from changing (Wagner & Ingersoll, 2013).

How does MI work? By adopting a collaborative partnership with clients, the MI-consistent provider engages in a conversation about change. In this conversation, the provider intentionally attends to client statements about change and intentionally uses communication strategies to elicit and explore a client’s own arguments for changing while minimizing arguments about remaining the same (Miller & Rose, 2009; Wagner & Ingersoll, 2013).

ere is commonality across all three of these de nitions. ese commonali- ties are essential components of any MI interaction and any training or research related to MI. ese common elements include:

MoTIVATIonAL InTeRVIeWIng oVeRVIeW

• MI is a particular kind of intentional communication about change.

is communication style can be used whether a provider is o ering

counseling, assessment/test feedback, supervision, or consultation.

• MI is collaborative. In using MI, the provider is focused on being a

partner—noT an expert!

• MI is evocative. To be MI-consistent, the provider’s focus is on eliciting

clients’ motivations and ideas about change versus prescribing them.

WHAT MOTIVATIONAL INTERVIEWING IS NOT

In 2009, Miller and Rollnick attempted to clear up several misconceptions about MI. In doing so, they developed a list of the common misunderstandings people have about this approach. Corrections to these misconceptions include:

Motivational Interviewing is Not Based on the Transtheoretical Model (TTM)

TTM and the accompanying stages of readiness change represent a set of attitudes, intentions and behaviors related to change that a person may hold depending on their readiness to change (Connors, DiClemente, Velasquez, & Donovan, 2013). In particular, the stages of readiness to change (precontempla- tion, contemplation, preparation, action, and maintenance) provide a frame- work for thinking about where clients are in the change process (Prochaska & Diclemente, 1983). Clients at the rst two stages of change are not committed to making change. A client who is at the precontemplation stage is not aware of a need to change whereas the client at the contemplation stage is considering the pros and cons of changing or not. e client at the preparation stage is put- ting plans into place to begin changing. Clients at the action and maintenance stages are actively working to modify a behavior or maintain changes already achieved.

early writings about MI linked it to the TTM (DiClemente & Velazquez, 2002; Miller, 1983; Substance Abuse and Mental Health Services Administration, 1999). o en this led people to think that MI cannot be used without the TTM. Although MI works well with the TTM and in particular the stages of change, it is not dependent on them. In particular, MI would be valuable for use with indi- viduals in the precontemplation, contemplation, and preparation stages more so than it would at the action and maintenance stages (Adams & Madson, 2006). e TTM provides a way of thinking about how people might approach change whereas MI provides us with an evidence-based communication approach that ts well with many theories of change (naar-King & Suarez, 2011). Although MI can be used at certain stages of readiness to change, its use is not dependent on these stages.

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Foundational Concepts and Skills 13

Motivational Interviewing Is Not a Way of Tricking People into Doing what They Don’t Want to Do

Many individuals we train have commented that MI seems like reverse psychol- ogy. e concept of reverse psychology refers to one person’s advocacy for a belief or behavior that is opposite to the one they desire for another person for the express purpose of manipulating the other into do something they are against doing. not only is this not what MI is, the idea is contradictory to: the foundation of MI, the compassion necessary to practice MI, and the ethical application of MI (Miller & Rollnick, 2013). In fact, to be MI-consistent, the provider is focused on the client’s own concerns, perception of the problem, motivations and rec- ognizing their autonomy to choose solutions that t best for them and not the provider’s own goals.

Motivational Interviewing Is Not a Technique

You can’t “MI” someone! on the surface MI looks easy, but it is a complex, planned communication process that requires active and intentional listening and selection of strategies by the provider. ere is also a foundational spirit that is essential to being an MI-consistent provider. By ignoring this spirit for tech- nique a provider would only be going through the motions, not using MI. We have observed many trainees “go through the motions” in trying to implement MI which resulted in poor client outcomes.

Motivational Interviewing Is Not Simply a Decisional Balance

Decisional balance is one strategy that can be used to elicit change talk. However, there are a variety of MI-consistent strategies that can be used in MI without ever using a decisional balance (Rollnick, Miller & Butler, 2008; Rosengren, 2009). Further, people we have trained and coached have incorrectly believed they were doing MI when they used the decisional balance while completely neglecting other MI principles and strategies. us, a provider can use a decisional balance without necessarily being MI-consistent.

Motivational Interviewing Is Not just Client-Centered Therapy or a Form of Psychotherapy

Madson, Schumacher, and Bonnell (2010) highlighted the similarities and dif- ferences between MI and client-centered therapy (Rogers, 1959). We expand this di erentiation by comparing MI to other common psychotherapies to demonstrate how it di ers from these approaches (see Table 2.1). e fact that MI is a communication style, not a type of psychotherapy, lends to its broad

14 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

Table 2.1. Comparison of Motivational Interviewing and Common Psychotherapies

Feature

Person- Centered

MI

Cognitive

Behavioral

Level of direction

Following

guiding

Directing

Directing

Focus in session

Feelings

Change talk

Cognitions

Behaviors

Form of psychotherapy

Psychotherapy

Communi- cation style

Psycho- therapy

Psycho- therapy

Length of contact

Long-term

Brief

Brief

Brief

essential ingredients

Core conditions

Spirit

Challenging maladaptive thoughts/ beliefs

Learning
a healthy opposite to problem behavior

Focus in session

exploration

Increasing change
talk and minimizing sustain talk

Maladaptive thoughts and beliefs

Problem behaviors

Transformative element

Resolving incongruence

Change talk

Learning adaptive thoughts and beliefs

Learning healthy behaviors

eory of personality

Developed

none

Developed

Developed

View of psychopathology

Incongruence

none

Learned patterns of thinking

Learned behaviors

applicability. is diverse applicability has contributed to the widespread prolif- eration of MI across di erent disciplines within and outside mental health and substance abuse treatment.

Motivational Interviewing Is Not Easy

ere is vast empirical support that developing competency in MI entails practice of skill and coaching to develop basic pro ciency (Madson, Loignon,

Foundational Concepts and Skills 15

& Lane; 2009; Madson, Schumacher, noble & Bonnell, 2013; Schumacher, Madson & norquist, 2011; Walters, Matson, Baer, & Ziedonis, 2005). In fact, the current gold standard for MI training involves practice with observa- tion and feedback to develop competency (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). Similarly, MI is not simply what you have already been doing. Collectively, we have spent 21 years learning, practicing, training and evaluating MI. our evolution involved relearning skills and a mind-set that was based on but di erent than what we had learned previously about work- ing with clients. We have found that that our personal MI learning experience as psychologists is consistent with the learning experience of professionals across the disciplines that utilize MI—certain communication styles and attitudes need to adjust to develop an MI-consistent practice (Schumacher, Madson & nilsen, 2014).

Motivational Interviewing Is Not an Answer for Everything

MI is not a panacea, and there are times when MI is not appropriate. For instance, when an individual is actively changing a behavior, you would want to employ active behavior-change interventions. At times like these MI would be contra- indicated (Adams & Madson, 2006). However, it is important to recognize that behavior change waxes and wanes. us, MI can be integrated with other change interventions at those times (Westra, 2012). In fact, given that MI is a commu- nication style focused on the client’s change, it can be successfully integrated with traditional change approaches such as medication management (Interian, Lewis-Fernández, gara, & escobar, 2013), case management (Leukefeld, Carlton, Staton-Tindall, & Delaney, 2012), patient education (gance-Cleveland, 2007), and cognitive and behavioral interventions (naar-King, earnshaw, & Breckon, 2013) you may currently be using. In fact, a major goal of this book is to help you learn how you can integrate MI with your current approaches to address speci c challenges you may face in working with clients.

Quick Reference
Motivational Interviewing Is Not

Based on the transtheoretical model Reverse psychology
A technique
Just using decisional balance Person-centered therapy

A form of psychotherapy easy to learn or use
An answer for everything

 

16 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

TWO COMPONENTS OF MOTIVATIONAL INTERVIEWING

In 2009, Miller and Rose described a theory of how MI facilitates change through a combination of relational and technical components. e relational and technical components of MI are not incompatible but are suggested to be underlying processes of MI (Madson et al., 2013; Martino et al., 2008; Moyers & Martin, 2006).

Relational component: grounded in the client-centered approach of Carl Rogers, this component includes an empathic, a rming, non-judgmental and autonomy-supportive counseling style intended to create a safe environment in which clients can explore their own wishes, fears, and concerns (Moos, 2007). In other words, the provider avoids imposing an agenda, basing acceptance on conditions, or arguing with or confronting clients, and instead actively listens to the client’s spoken and unspoken messages in order to remain MI-consistent.

Technical component: Built on the relational foundation, a provider uses strategies aimed at eliciting clients’ in-session change talk and decreasing their sustain talk with the overarching goal of evoking commitment to change (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003; Miller & Rose; 2009; Moos, 2007). In other words, the provider works with clients, listens intently, engages in MI-consistent behaviors, and utilizes strategies that elicit and reinforce cli- ent statements about desire, ability, reason, and need to change (Moyers & Martin, 2006).

THE FOUNDATIONAL SPIRIT OF MOTIVATIONAL INTERVIEWING

e foundation of MI, o en called the “spirit,” can be summarized by four char- acteristics that need to be present in any MI-focused provider-client relationship. ese characteristics are collaboration, evocation, acceptance, and compassion (Miller & Rollnick, 2013). ese characteristics are necessary for a provider to successfully use MI and are more important than any speci c strategy. In fact, the spirit of MI is the foundation from which any MI interaction develops. For this reason we provide further explanation of each characteristic of the MI spirit with MI-consistent and MI-inconsistent examples.

COLLABORATION

MI depends on a relationship between the client and provider that resembles a partnership. Instead of directing the client and using the presumed power dif- ference, providers and clients participate in a discussion regarding behavior change. As such, it is important that providers recognize that they have certain expertise or experience, and at the same time their clients also have expertise and experience about themselves and previous change e orts. is collaboration is a de ning point of MI because ultimately behavior change is in the hands (or

Foundational Concepts and Skills 17

control) of the client. is relationship is conducive (i.e., facilitative or contribut- ing) to change, not coercive.

Example: MI-Consistent/Inconsistent Collaboration

Client Statement: “Look, I just smoke a little pot [marijuana]. I don’t think it is that big of a deal, but I failed a drug screen at work and they made me come here. So, I have to quit now, even though I don’t see anything wrong with it.”

MI-Inconsistent: “Pot is illegal and against your work policy. If you want to stop, this program will get you on track.”

is response is considered MI-inconsistent because the provider assumes an expert/authoritarian role. In this role, the provider is not working as a partner but is “telling” the client how it is and how to behave. is response is more likely to increase discord (discussed later) between the client and provider, not develop a partnership.

Somewhat MI-Consistent: “You’re faced with a forced change to keep your job and that isn’t too exciting for you. I’ve told you about our program. How will it work for you?”

is response is somewhat but not completely MI-consistent. e provider re ects the client’s concern about being forced to change and attempts to elicit solutions from the client. However, the provider still communicates that the client must gure out how to make the program work, which com- municates an expert role.

MI-Consistent: “Sounds like you are really frustrated and feel like you are being forced into changing. Since the circumstances are the way they are, I wonder if we can brainstorm and work together to come up with some ideas on how we can make the most of our time together.”

is response is an MI-consistent, collaborative response. not only does it acknowledge the way the client is feeling about the session without correct- ing the client about using marijuana, but the provider adopts an egalitarian approach asking how the two can best utilize their time. e statement also communicates that the provider wants to work with the client in best utiliz- ing their time versus imposing an agenda of what to address. us, the two are partners.

EVOCATION

Traditionally, many behavior change approaches tend to focus on determining what clients lack or need and on lling that gap (e.g., medication, knowledge, skills). us, providers o en adopt a prescriptive approach determining what clients need and telling them how to change. Clients o en push back to this

18 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

approach, explaining why it may not work. Rather than engage in that back and forth, the MI-consistent provider focuses on drawing information out of the cli- ent (Miller & Rollnick, 2002). is may include eliciting from clients (1) their perspective of the problem; (2) why they may want or need to change; (3) how they would change; (4) personal goals and values; (5) why they may not want to change; or (6) why they may want to stay the same. While a client may lack the “desired level” of motivation, all individuals are somewhat motivated to make changes and every client has ambitions, values, and concerns. A goal in MI is to establish a personal connection between the change focus and what the client values. By identifying client’s aspirations and perspectives, a provider can evoke from clients their own arguments for making changes. In MI, this is referred to as “change talk.”

Example: MI-Consistent/Inconsistent Evoking

Client Statement: “Well I’m here. My physician said I needed to see you about my diet and exercise before I had my procedure.”

MI-Inconsistent: “It is good you are here. We need to get you on a healthy diet and exercising each day. I have a plan that has been really successful”

is is an MI-inconsistent response because the provider does not evoke anything from the client. e provider also prematurely focuses on a change target and adopts an expert/authoritarian role. e provider is not attempt- ing to understand any aspect of the client’s view of the concern. It is highly likely that the discussion will evolve with the client explaining why the plan wouldn’t work. Without understanding the client, the provider is likely to evoke more sustain talk than change talk.

Somewhat MI-Consistent: “ anks for coming in today at the request of your physician. What things should you change about your diet?

is response is somewhat but not completely MI-consistent. e provider a rms that the client followed through on the request of the physician in an MI-consistent fashion. e provider also asks an open question. However, the speci c open question selected by the provider focuses the encounter on changes in diet in a non-collaborative fashion—the provider chooses what is important without seeking client input. Additionally, the choice of the word “should” communicates that the client has to do something.

MI-Consistent: “It sounds like your physician wanted you to see me to work on your diet and exercise. What are your thoughts about seeing me?”

is is an MI-consistent, evocative response as it not only re ects the cli- ent’s understanding of the referral but it also elicits from the client his/her own ideas about the consultation. e response communicates that the client’s ideas are the important ones in this conversation. is avoids the premature focus and assuming an expert role. Responding in this way also avoids the trap of taking sides. Unlike previous responses, this one does not align the provider with the physician—taking sides.

Foundational Concepts and Skills 19

ACCEPTANCE

Although not new to counseling or to MI; acceptance has recently been explic- itly identi ed as the third foundational component of MI (Miller & Rollnick, 2013; Wagner & Ingersoll, 2013). Acceptance involves appreciating what the client brings to the interaction. In MI, an accepting environment helps the cli- ent explore all aspects of change. is does not mean that the provider has to approve of the client’s actions or give in to the status quo (Miller & Rollnick, 2013). Acceptance, as outlined by Miller and Rollnick includes four aspects.

Absolute Worth

A basic tenet of person-centered therapy is that every human is trustworthy and has potential to change and to do the best for themselves (Rogers, 1959). Recognizing the potential and worth in every client is essential to developing a solid relationship and communicating acceptance.

Accurate Empathy

To be MI-consistent, a provider has to have a genuine interest in and desire to appreciate and understand the client’s situation. is does not mean feeling sympathetic towards or identifying with clients. It does mean that MI-consistent providers actively seek to understand the world of their clients and how that relates to their change or lack of change. For instance, if a client was not tak- ing her/his medication, a provider would be MI-consistent by seeking to bet- ter understand the client’s situation, values, and goals to see how they relate to change versus simply lecturing the client about the need to take the medication. Accurate empathy communicates that the provider is interested in clients’ expe- rience and wants to learn what it is like for them.

Respecting Client Autonomy

MI depends, in part, on the provider’s separation from the client’s nal deci- sion to make a change. is does not mean that MI-consistent providers avoid caring about their clients; instead, it implies recognizing that individuals are responsible for their decision making. is is a di cult concept for many pro- viders to accept. However, we o en remind those we train that they do not follow their clients 24 hours a day, 7 days a week. Clients must make their own decisions about what they think is best for them all the time—so why not embrace this fact? A provider can o er information, advice, and feedback, but ultimately, the decision to make a change is on the client. Acknowledging the clients’ autonomy to decide o en aids in the process of change as they

20 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

recognize they have the freedom and ultimate responsibility for making changes how they deem appropriate.

Af rmation

As a strength-based approach to counseling, MI-consistent providers strive to recognize, comment on, and elicit client strengths and resources (Madson, Loignon, Shutze, & necaise, 2009). Most individuals who seek help, whether by choice or coercion, have likely attempted to change in the past with variable suc- cess. o en clients focus on failures at change or thwarted e orts. In a rming clients, the goal isn’t to be a cheerleader or o er positive a rmations—it is to help clients see their strengths, resources, and previous success from which this change e ort may be built

Example: MI-Consistent/Inconsistent Acceptance

Client Statement: “Look at this scar on my face. I don’t know why the police arrested me, I was just defending myself. She’s crazy!”

MI-Inconsistent: “I hear you. An important part of xing this problem is accepting responsibility for your behavior. at will help keep you out of jail.”

is response is MI-inconsistent because the provider directly confronts the client. e response conveys that the provider has taken the side of the client’s partner and the criminal justice system, is not interested in hearing the client’s perspective, does not respect the client’s right to make choices, and is critical rather than a rming. It is highly likely that this response would reduce the client’s ability to engage with the provider and use the interaction to actively consider what types of changes he might need or want to make in his life.

Somewhat MI-Consistent: “You do not believe that the police listened to your side of the story and are uncertain you belong in this treatment. How can we ensure you keep out of trouble?”

is response is somewhat MI-consistent. e provider resists the righting re ex and instead re ects the client’s perception of the situation. e pro- vider also attempts to evoke potential solutions from the client. However, there is little e ort to communicate the elements of acceptance.

MI-Consistent: “You do not believe that the police listened to your side of the story and you are not certain that you belong in this treatment. Given that you feel that way, I appreciate that you kept this appointment and showed up anyway. Ultimately you will have to decide what if anything you can learn from this program.”

is response is MI-consistent because it conveys that the provider has heard and is trying to understand the client’s perspective on his current situation, and thus conveys empathy. e response also a rms that the

Foundational Concepts and Skills 21

client’s willingness to keep his appointment is a strength and acknowledges that the client has the autonomy to decide what he will do. Taken together, this willingness to listen to the client, support his autonomy, and recognize his strengths convey clearly that the provider values the client and recog- nizes his absolute worth as a person.

COMPASSION

Compassion is an authentic, emotional response when perceiving others’ su er- ing and results in a desire to help (Seppala, 2013). In other words, compassion includes a sense of responsibility and care for human beings that intensify their motivation and drive to better their clients’ lives (Fromm, 1956). us, in practic- ing in an MI-consistent fashion, it is essential to always have the best intentions for your clients and genuinely care about their welfare. However, it is important to avoid the righting re ex (discussed later) as a result of concern for the welfare of and wanting to do good for others.

Example: MI-Consistent/Inconsistent Compassion

Client Statement: “Isn’t there anything you can do to save my foot?”

MI-Inconsistent: “We have been working with you for years to try to get you to better manage your blood sugar. I’m sorry but at this point there is nothing we can do. Hopefully this situation will help you better manage your diet and medications in the future so you don’t also lose your other foot.”

is response is considered MI-inconsistent, and might well represent a response from a provider who is experiencing burnout. Although the response contains factual information that addresses the question asked by the client, it does so in a confrontational fashion and without compassion for the client’s current state of emotional distress and need for comforting and reassurance as well as information.

Somewhat MI-Consistent: “You are very upset about losing your foot. What can you take from this situation about how to avoid future losses?”

is response is somewhat MI-consistent. e provider re ects the cli- ent’s feelings and attempts to elicit rather than confront the client. However, the client may experience the response as judgmental and non-compassionate given the focus isn’t on relieving the pain but how the client can learn from this experience.

MI-Consistent: “I can tell you are very upset about losing your foot, and I wish there was something I could recommend that would save it.”

is response is an MI-consistent, compassionate response because it con- veys empathy with the client’s current emotional distress as well as a desire to resolve that distress. is response may open the client up to using the provider as a source of emotional support during a di cult life transition

22 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

and to working with the provider to try to better manage his or her diabetes in the future.

Quick Reference
Foundational Motivational Interviewing Spirit Components

entering into a collaborative working relationship
eliciting from clients versus prescribing to them
Appreciating client worth and autonomy, a rming strengths, and empathiz-

ing with their situations
A sense of care and responsibility for the welfare of clients

FOUR GUIDING PRINCIPLES

Although not included in some of the most recent writings on MI (e.g., Miller & Rollnick, 2013), in our work as MI trainers, we have found that the four guid- ing principles of MI, as elaborated by Rollnick, Miller, and Butler (2008), help many providers improve their grasp of the foundational spirit of MI. ese prin- ciples are (1) resisting the righting re ex, (2) understanding and exploring the client’s motivations, (3) listening with empathy, and (4) empowering the client and encouraging hope and optimism. It can be helpful for providers to remem- ber the acronym, RULe: Resist, Understand, Listen, and empower in relation to remaining MI-consistent.

R: Resist the Righting Re ex

Providers tend to want to heal pain, make things right, and endorse well-being. us, when providers witness someone making poor choices, they have a strong urge to try to stop the individual or set them in the “right direction.” is motivation is what makes the desire to correct someone’s behavior an auto- matic re ex (i.e., righting re ex). However, providers who give into the urge to correct o en experience the opposite of what they hope to achieve. Instead of choosing to change a behavior when they are told to do so, clients o en resist change, particularly when they sense persuasion. is is not because clients are lazy, contrarian, or even in denial concerning their need to make a change. Instead, people are naturally inclined to push back against another’s attempt to in uence their behavior (Le ngwell, neumann, Babitzke, Leedy, & Walters, 2007). is push-back is particularly powerful when someone is experiencing ambivalence (i.e., feeling two ways about the same thing) toward a behavior. For example, overeaters o en are aware that their eating is problematic, and

 

Foundational Concepts and Skills 23

they are o en aware of some of the negative consequences of their eating. At the same time, these individuals enjoy food, recognize the role food may play in socialization, and do not want to see themselves as having an “eating prob- lem.” Instead they would rather see their eating as normal. us, these indi- viduals o en simultaneously feel two ways about their eating behavior—both for and against changing it.

When clients see providers “taking sides” with the healthy part of the client’s ambivalence, making a case for why they need to change, their natural response will be to make an argument against making a change (Le ngwell et al., 2007). Consequently, the provider’s re ex may be to make a stronger argument, which will likely cause a client to argue more. Because people have a tendency to believe what they hear themselves say, a provider’s arguing with a client may actually be solidifying the client’s argument against making a behavior change. In MI, the client should be the one who is making a case for change, not the provider. Because many clients are ambivalent about making changes, it is the provider’s job to help them work through this ambivalence and aid them in making a case for a change. To be MI-consistent, a provider needs to understand ambivalence as a natural part of change and not as pathological. is stance helps providers avoid educating or persuading clients to change—resisting the righting re ex. erefore, MI-consistent providers use a variety of strategies to highlight and explore client ambivalence, including questioning, simple and complex re ec- tions, a rmations, and summaries (Miller & Rollnick, 2002).

Example: Resisting the Righting Re ex

Client Statement: “Look, I wish everybody would just leave me alone about my HIV. I get what they are saying about needing to stay on top of my treatment and sexual behavior, but I feel ne and all my friends have unprotected sex.”

MI-Inconsistent: “You don’t seem to be as worried about your HIV as every- one else. Don’t you think it is important to address?”

“What about trying to always have a condom with you in case you have sex?”

ese two provider statements are MI-inconsistent and illustrate two dif- ferent ways the righting re ex can manifest itself in working with ambiva- lent clients. e rst statement directly confronts the client’s ambivalence as denial in a direct attempt to get the client to reconsider his or her per- spective. Likely this statement will engender discord between the client and provider. In the second statement, the provider succumbs to o ering unsolicited advice and prescribes a solution. It is likely that the client will respond by discussing how the solution will not work.

Somewhat MI-Consistent: “You recognize that change is hard and also rec- ognize that others have concerns about your HIV and believe that you may need to change your behavior. It seems important to keep yourself and others safe in the future.”

MoTIVATIonAL InTeRVIeWIng oVeRVIeW

is response is somewhat MI-consistent. e provider provides a nice double-sided re ection that highlights the client’s ambivalence. However, rather than simply highlighting the ambivalence, the provider attempts to resolve it for the client by siding in favor of change. e client is likely to respond with talk about not changing.

MI-Consistent: “You recognize that change is hard and also recognize that others have some reasonable concerns about your HIV and believe that you may need to change your behavior. Tell me where this all leaves you.”

e provider is re ecting the ambivalence the client obviously feels about making changes to his or her HIV-risk behavior. is helps convey to the client that the provider understands his or her dilemma and is not judging the client. By following up with a “Tell me” statement that invites the client to explore further why he or she might consider reducing HIV-risk behav- ior, the provider actively works to help client resolve ambivalence.

U: Understand the Client’s Motivations

each client has reasons for making a change, and those reasons will be more likely to persuade them to change than your reasons (neighbors, Walker, Ro man, Mbilinyi, & edleson, 2008; Rollnick et al., 2008). Being interested in a client’s own motivations and values is an important part of eliciting from clients and increasing their motivation to change. Because consultation time with each client is limited, this may sound unreasonable and like a waste of time. However, as previously out- lined, the provider voicing of reasons for change can actually be counterproductive and cause the client to voice arguments against change. us, from an MI per- spective, your limited time is better spent asking clients why they are interested in making a change than telling clients why they should change. is principle again is focused on the client voicing the reasons for change, not the provider.

L: Listen to the Client

MI requires listening to clients with empathy in order to understand their reasons for making a change. Although providers are o en viewed as the “experts” on a subject (e.g., good nutrition, medication, behavior change), typically answers to questions involving how and why change will occur for a particular client come from the client. e skill of listening is essential for gathering these answers.

E: Empower the Client

When clients take an active role in the decision-making process and feel empow- ered to make a change, the outcomes are typically more positive and changes are

24

Foundational Concepts and Skills 25

o en made. While providers may be knowledgeable regarding speci c aspects of changing such as how to diet, take medications, manage anxiety, and how change will improve the client’s life, the client is the expert on how to t the change into his or her daily life. erefore, a client will likely know how to best accomplish the goal of change. In this process, it is the provider’s role to o er support of the client’s belief that he or she can make a change and to help the cli- ent feel comfortable sharing his or her expertise in the consultation.

BASIC MOTIVATIONAL INTERVIEWING SKILLS

Basic counseling skills are vital to interactions across several helping professions from medicine to corrections. In MI, these basic counseling skills are used inten- tionally and purposefully during the course of an interaction in order to facili- tate client discussions about changing (change talk) and to minimize discussions about not changing (sustain talk). In other words, providers can use these basic counseling skills to elicit and selectively reinforce client discussions in favor of changing and to guide clients away from discussions related to not changing. e skills emphasized in MI are represented by the acronym oARS—open ques- tions, A rmations, Re ections, and Summaries (Miller & Rollnick, 2013).

Open Questions

e appropriate use of questions is an important aspect of MI. Providers must be mindful in sessions to avoid the question and answer trap. is trap is a cli- ent/provider interaction in which the provider overuses questions (o en closed questions) and the client simply answers the questions with limited responses. is trap results in a question-a er-question and answer-a er-answer pro- cess that prevents a deeper discussion of the topic (Miller & Rollnick, 2002). MI-consistent providers avoid trying to ask more than one question in a row to avoid this trap!

open vs. closed question: A closed question implies or requires the client to give a one- or two-word answer (e.g., yes or no) and is used to gather speci c information (Hill & o’Brien, 1999; Seligman, 2008). An open question is broad; encourages clients to talk about thoughts, feelings, behaviors, and/or experiences; and give clients exibility in how to respond (Hill & o’Brien, 1999; Seligman, 2008). In MI, the use of open questions is preferred to closed questions as open questions are more eliciting and invite clients to provide more information than closed questions.

Example: MI-Consistent/Inconsistent Questions

Client Statement: “I can’t seem to remember to take my evening medications.” MI-Inconsistent Closed Questions:

26

MoTIVATIonAL InTeRVIeWIng oVeRVIeW

“Have you been following your diet?”

“Don’t you think it is important to take your medications?”

ese questions are MI-inconsistent, and not simply because they are closed questions. e rst question is not in sync with what the client is talking about and could communicate that the provider is not listening or does not care about the client’s concerns. e second question, while on topic, is a rhetorical question that could appear judgmental to the client and engender discord.

Somewhat MI-Consistent Closed Questions:

“Have you thought about setting an alarm as a way to remind yourself?”

“Do you use a pill organizer to help you keep up with your pills?”

ese closed questions are not as MI-inconsistent as the prior examples, but are also not fully MI-consistent. Although the provider is not directly giv- ing unsolicited advice about how to improve medication adherence, which would clearly be MI-inconsistent (Miller & Rollnick, 2013), the provider is using these closed questions as an indirect way to give such advice.

MI-Consistent Closed Questions:

“How long have you had this di culty?”

“Do you have di culty taking your other medications?”

While these are closed questions, they are MI-consistent as they are attempt- ing to elicit from the client his or her thoughts about the problem and avoid prescribing a solution or placing judgment on the situation.

MI-Inconsistent open Questions:

“How can I make you understand the importance of taking your medications?”

“How has your diet been?”

ese questions, while open, are MI-inconsistent. With the rst question, the provider seeks to directly confront the client about medication com- pliance, which is MI-inconsistent. e second question is not in sync with what the client is discussing and thus shows a lack of collaboration and empathy.

Somewhat MI-Consistent open Questions:

“What will help you remember?”

“What are your thoughts about using a pill-minder to help you remember?”

ese questions, while open and inviting the client to talk, are not fully MI-consistent. e rst question immediately attempts to identify solutions and a plan for changing. It is not fully MI-consistent as it doesn’t consider client motivation for changing or not. ere is a potential for the discussion to quickly evolve to the point at which the provider o ers solutions and the client rejects them (i.e., righting re ex). e second question is used to elicit the client’s reactions; however, the question is focused on the provider’s

Foundational Concepts and Skills 27

solution, rather than eliciting solutions from the client. us the provider is using the question as an indirect way to o er unsolicited advice.

MI-Consistent open Questions:

“What concerns you about taking and not taking your medications?” “What exactly happens in the evening?”
“What are some reasons you want to take your meds
?”

ese questions are MI-consistent because they invite the client to talk and they elicit the client’s expertise about the situation thus allowing providers to gain a better understanding of the client’s motivations and concerns. In fact, a question like the third question is likely to elicit change talk (dis- cussed later)—an important aspect of MI as it relates to increasing motiva- tion. e rst two questions will help the client discuss concerns associated with medications and barriers that might need to be addressed to enhance motivation for changing.

Af rmations

When clients are attempting to change, it is common to focus on the problem or past failed attempts. Correct use of a rmations is a method through which client strengths can be emphasized. A rmations, in MI, involve actively seek- ing to uncover, recognize, and discuss client strengths and positive actions (Hohman, 2012; Pirlott, Kisbu-Sakarya, DeFrancesco, elliot, & MacKinnon, 2012). To accomplish this, a provider may comment on a strength, attri- bute, skill, or action; reframe an action, situation, or attribute in a positive light; or elicit a rmations from the client. Using a rmations does not mean a provider acts like an overzealous physical trainer or cheerleader, but that the provider genuinely elicits, recognizes, and comments on client strengths. erefore, a rmations should focus on the client, should not be “praise,” and should avoid using the word “I” as in “I approve”. In the helping professions, it is common for providers to use comments like “that is good/great” or “I am so proud of you.” ere is no doubt in our mind that these comments are meant to be supportive; however, they are not fully MI-consistent as they violate these rules.

Example: MI-Consistent/Inconsistent A rmations

Client Statement: “My family says I am depressed but I am not sure. I go to work and socialize. Don’t depressed people just sit at home and sulk.”

MI-Inconsistent: “You are depressed and not sure what to do about it.”

Although this is a nice example of a simple re ection (discussed later), it focuses solely on client weaknesses and problems. us, there is little attempt to recognize or comment on strengths. Additionally, it has the

MoTIVATIonAL InTeRVIeWIng oVeRVIeW

potential to engender discord between the client and provider as the client has communicated uncertainty about being depressed.

Somewhat MI-Consistent: “Your family thinks you’re depressed but depressed people do not behave the way you are. I am happy you still came in.”

is statement is an example of a good re ection of content. However, the provider misses an important opportunity to a rm the client by com- menting on strengths, successes, or positive behavior. Further, the pro- vider by using “I” puts the focus on her or his approval versus the client’s inherent strengths or abilities.

MI-Consistent:
Comment on positive action: “You came here at the request of your family

even though you are unsure if it is needed. You must care a lot about them.”

Reframe situation: “You are feeling depressed and are coping with it pretty well. You’re still able to work every day and go out with friends.”

elicit from client: “What sets you apart from those people who sit at home and sulk?”

each statement is an MI-consistent a rmation as they follow the rules out- lined earlier, focus on strengths, and are likely to engage the client in fur- ther discussion versus engendering discord between the client and provider. e rst statement acknowledges that the client is uncertain about having depression yet highlights the care for family members resulting in coming to the appointment. e second statement reframes the client’s focus on sitting home and sulking to focus on the strength of being active. e third state- ment elicits from the client qualities that can be used as strengths in changing.

Re ections

As the primary basic counseling skill used in MI, re ections are important as they help bridge the meaning between what the client is communicating and what the provider hears, and allow providers to check their understanding of what was said (Passmore, 2011; Rosengren, 2009). It is important to note that when o ering a re ection, the tone of voice is just as important as the words uttered. To re ect, the voice should in ect down at the end of the statement. An up-in ection at the end of the statement, which seems to come most naturally to most people we have trained in MI, communicates a question—a closed ques- tion. To be MI-consistent voice tone should also be devoid of in ections that convey sarcasm, hostility, or condescension.

Re ections are valuable as they can (1) help demonstrate that a provider is listening, (2) express provider empathy, (3) communicate an understanding and appreciation of the client, and (4) help the provider guide the client to a deeper discussion of the topic. For these reasons, it is also important to avoid tagging on a question such as “Right?” or “Is that correct?” ose types of questions can

28

Foundational Concepts and Skills 29

convey to the client that the provider does not really understand them and must check-in frequently in order to follow them. Re ections should also be used intentionally in MI to strategically re ect sustain talk, discord and change talk as providers seek to guide clients toward change. e goal in using re ection with discord is to join with the client rather than confront him or her about their ambivalence toward change. When intentionally re ecting discord, a provider is continuing to understand and foster an engaging working relationship (Miller & Rollnick, 2013). Change talk is a key aspect for facilitating change in MI, and as such the MI-consistent provider re ects change talk in an attempt to reinforce and strengthen it (Miller & Rollnick, 2013).

An MI re ection is categorized as simple or complex.

Simple Reflections

Re ections that remain very close to what the client said, adding little additional information, are simple re ections (Moyers, 2004). Simple re ections are o en used to acknowledge and validate what the client is saying (Rosengren, 2009; SAMSHA, 1999). us, simple re ections may include statements about basic client feelings and thoughts or session content. Sole reliance on simple re ections can slow progress of the discussion to more meaningful aspects of the client’s concerns. o en when our trainees felt their sessions went around in circles with little progress, we found that they relied mainly on simple re ections and didn’t deepen the discussion.

Example: MI-Consistent/Inconsistent Simple Re ections

Client Statement: “My wife bugs me about eating healthy. I can’t believe she made me come here.”

MI-Inconsistent: “Your eating is bad.”

is re ection is MI-inconsistent because it negatively labels the client’s eat- ing and is likely to engender discord. e re ection prematurely focuses on the eating behavior and misses the client’s message about being upset over being forced to come to the session. is missed opportunity to re ect the client’s concern could slow engagement and the development of the work- ing relationship. Instead, the client could become defensive about his eating behavior.

Somewhat MI-Consistent: “Sounds like you and you wife are having some di culties.”

is re ection is somewhat MI-consistent. It is a re ection of the session content but is likely to focus the discussion on the client’s wife or marital relationship. us, the discussion may end up o moving away from the potential change target and may lose focus.

MI-Consistent: “You can’t believe you’re here.”

is re ection is MI-consistent because it focuses on the message commu- nicated by the client. By re ecting the content of the statement, the pro- vider validates the client’s comment and is more likely to foster trust and

30 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

engagement. e re ection communicates that the provider hears where the client is coming from and that his situation is appreciated. erefore, this re ection is less likely to engender discord.

Complex Reflections

Complex re ections are an important ingredient in helping to facilitate client change within the framework of MI because they expand on the discussion. Complex re ections are provider restatements of session content, and client thoughts and/or feelings with substantial emphasis or meaning added to facili- tate movement toward positive change (SAMHSA, 1999).

Types of Complex Re ection

Double-sided Re ection: e double-sided re ection is o en used in MI. A double-sided complex re ection occurs when the provider restates a client statement that captures both sides of ambivalence (Miller & Rollnick, 2002). us, use of double-sided re ections helps to bring to awareness the ambivalence the client is experiencing without siding one way or the other.

Example: MI-Consistent/Inconsistent Double-sided Re ection

Client: “I know people want me to completely stop smoking, but I am not going to completely quit.”

MI-Inconsistent: “Smoking is good and you don’t want to quit.”

e provider’s response is a nice re ection of sustain talk. However, it is not an MI-consistent, double-sided re ection because it does not capture both sides of the client’s ambivalence. e re ection only focuses on why the client wants to continue smoking. is could result in the client talking further about not quitting.

Somewhat MI-Consistent: “You are aware that others are concerned about your smoking and at the same time are not ready to quit smoking completely.”

In this re ection the provider captures both sides of the client’s ambiva- lence. However, it is somewhat MI-consistent as the second half of the double-sided re ection focuses on not changing. given that clients are likely to pick up the conversation where providers leave o , this client is likely to talk more about continuing to smoke instead of changing smok- ing behavior. Although an expert-level MI provider might sometimes intentionally structure a double-sided re ection in this way, generally speaking this is not the most MI-consistent ordering.

MI-Consistent: “You are not ready to quit smoking completely, and at the same time you are really aware that others are concerned about your smoking.”

In this re ection, the provider captures both sides of the client’s ambivalence, recognizing the concern about smoking and the lack of readiness to quit. us, both sides are re ected back to the client without an emphasis on either. ere

Foundational Concepts and Skills 31

are two important nuances in this re ection. First, notice the use of and versus but when using a double-sided re ection as it emphasizes feeling two ways. next, notice that the side of ambivalence related to changing is presented last. is point highlights one of the intentional aspects of MI. People o en continue to talk about the most recent thing another person states. us, the client is more likely to continue talking about reasons to change because the provider ended the double-sided re ection with the pro-change side of the ambivalence.

Ampli ed Re ection: is type of complex re ection occurs when a provider restates what the client has said, but in a stronger or even more extreme fashion than what the client communicated (Miller & Rollnick, 2002; SAMHSA, 1999). Ampli ed re ections are particularly helpful in responding to client sustain talk as it ampli es the client’s communication about not changing beyond what the client is saying, yet does not confront or challenge it. When using ampli ed re ection, it is important to remain supportive and avoid a tone that could be perceived as judgmental or condescending as this could engender discord.

Example: MI-Consistent/Inconsistent Ampli ed Re ection

Client: “I don’t understand why my wife is so concerned about my cholesterol. My results suggest it is borderline high, not high.”

MI-Inconsistent: “You really don’t have any problems whatsoever.”

is ampli ed refection is MI-inconsistent for two reasons. First, we highlight the potential tone of the word “really” as this could be perceived by the client as judgmental. Avoiding quali ers such as this might reduce that perception. Second, using “whatsoever” could be perceived as sarcastic and confronta- tional and could communicate that the provider does not believe the client.

Somewhat MI-Consistent: “Your wife shouldn’t have any concerns about you.”

In this re ection the provider is amplifying the client’s statement. However, the statement is a more global statement about the client’s relationship with his wife versus an ampli ed statement about the change target. e client may respond with discord or the conversation may dri o topic and lose focus.

MI-Consistent: “Your wife is worrying needlessly about your cholesterol.”

In this re ection the provider is amplifying the client’s statement about his wife’s concern by adding the word “needlessly”. By adding this word the provider is taking the client’s statement to an extreme that the client may actually disagree with and correct the provider.

Summaries

Summaries fall on the advanced end of re ections. In essence, summaries are provider statements that pull together and synthesize a group of client state- ments. To put it in the metaphorical terms of one of our non-MI passions (making

32 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

Southern barbeque): if re ections are individual spices, then summaries are the exquisite spice rub that pulls all of the individual avors together to give your barbeque just the right taste. Summaries can be used to begin and focus a ses- sion, close a topic, conclude a session, connect session content, and/or help a client re ect on what he or she has said (Ivey & Bradford Ivey, 2003; Seligman, 2008). Summaries are valuable to discussions about change as they allow clients to hear multiple aspects of their conversation all at once. In MI, you use sum- maries to selectively attend to key concepts (i.e., change talk) when choosing what to include. ree di erent types of summaries have been discussed and are described here.

Example: Summaries

Provider Question: “If you were to be successful in making the changes to your drinking we’ve talked about, what would be di erent in your life a year from now?”

Client Statement: “Well, if I make it through this DUI [arrest and conviction for driving under the in uence of alcohol] and get my license back, I’d have a job again.”

Provider Response: “So one thing is that you’d be able to get a job again. What else would be di erent?”

Client Statement: “Well, this isn’t really a change from now, but it is a change from beforenow that I don’t go to the bars, I’m spending more time with my kids. Doing homework, eating dinner with them; you know, just normal family stu .”

Provider Response: “So being a more involved father is something you’ve been doing and you think would continue a year from now. What else might be dif- ferent if you were successful in changing your drinking?”

Client Statement: “I’m not sure. I would hope maybe I’d be able to quit smok- ing. I’ve tried to quit before, and going to bars always makes me want to smoke. I guess if I didn’t go to bars maybe I could quit smoking.”

Collecting Summaries: ese are summaries that re ect information gathered over a period of time that are intended to simply continue the conversation (Rosengren, 2009). In essence, the provider is recalling several things a client recently stated. We have discussed with trainees that collecting summaries can be a great way to remain MI-consistent in intake or assessment sessions as they communicate the provider is listen- ing and enable probing for more information about a topic without simply asking questions.

Example: MI-Consistent/Inconsistent Collecting Summaries

MI-Inconsistent: “So you recognize the way your behavior has damaged your family both nancially and emotionally and you plan to nally be a respon- sible father and provider.”

Foundational Concepts and Skills 33

is summary is MI-inconsistent because it not only summarizes the cli- ent’s statements, but it also labels the client’s behavior in a negative way that does not convey acceptance.

Somewhat MI-Consistent: “So you hope to have a job. You also said you’d like to quit smoking. Am I hearing you correctly?”

is response is somewhat MI-consistent as is summarizes pieces of the dis- cussion. e focus of the summary is on the two things the client wants to change without including the bene ts of the changes discussed by the client. us, this summary may or may not promote positive change. e provider also uses a closed-ended question to “check” the accuracy of the summary.

MI-Consistent: So one thing you hope would be di erent a year from now is that you will have a job. You have been spending more time with your kids and want that to continue. You also said you’d like to quit smoking and you think that might be possible if you aren’t drinking at bars. What steps have you already taken toward making the changes in your drinking that will make all of those things possible?”

is summary is MI-consistent, because it pulls together what the client has said without labeling or judging what has been said, and it also focuses on the elements of what the client has said that are most likely to promote positive changes in the client’s drinking.

Linking summaries: When a provider wishes to connect information expressed by a client with previous information, a linking summary can be used (Rosengren, 2009). In using linking summaries the provider is inten- tionally trying to bridge di erent things the client has stated.

Example: MI-Consistent/Inconsistent Linking Summaries

MI-Inconsistent: “In looking through your chart, I see that this is your fourth time in treatment. I can’t believe you are still getting DUIs and going to bars almost every night. You need to get your act together and take treatment seri- ously this time.”

is summary is MI-inconsistent because it confronts the client about his drinking behavior and also blames him for past treatment failures.

Somewhat MI-Consistent: “So it sounds like a lot would be possible if you quit drinking, including smoking cessation. I’m glad to hear that you are considering smoking cessation now. at’s a big change. I can see from your chart that you’ve declined smoking cessation counseling the last several times it has been o ered.”

is summary is a somewhat MI-consistent linking summary. e pro- vider uses a summary to link something the client has just said to informa- tion from the client’s treatment record. However, the summary is not fully MI-consistent, because the provider shi s the established focus of the ses- sion from reducing alcohol consumption to smoking cessation.

MI-Consistent: “So you think a lot of important goals, like getting back to work, spending time with your kids, and quitting smoking might be possible if you were

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to make changes to your drinking. is sounds similar to the way you turned your life around when you le the gang to join the military when you were 18.”

is summary is MI-consistent because it links what the client has just said about making changes in his drinking to comments he made about other successful behavior changes, in a way that is likely to promote the client’s sense of self-e cacy about the current behavior change.

Transition summaries: e intention when using a transition summary is to shi between topics or to change topics (Rosengren, 2009). Transition sum- maries can be particularly useful during data-gathering interviews such as intake or diagnostic interviews as they communicate that the provider is listening and they help ease into the next aspect of the interview.

Example: MI-Consistent/Inconsistent Transition Summaries

MI-Inconsistent: “So it sounds like this DUI was nally the wake-up call you needed. You’ve recognized that your drinking is destroying you and your fam- ily. Admitting you have a problem is the rst step. How long have you been drinking?”

is provider utterance is MI-inconsistent. With the summary, the provider twists the change talk the client has o ered in a very negative, confronta- tional, and labeling way. e provider then transitions to asking structured questions without informing the client about the shi or asking permission to make the shi . us the provider controls the direction of the session is a very non-collaborative fashion.

Somewhat MI-Consistent: Just to summarize, you seem clear on wanting to stop using alcohol. Now let me go ahead and ask you some questions for our intake form.

Although this provider statement, in some sense, captures the essence of the conversation with the client up to that point, it is also not a summary. It does not bring together two or more distinct ideas expressed by the client. e provider also misses the opportunity to support client autonomy and main- tain a collaborative spirit by asking permission to segue to the intake form.

MI-Consistent: “Before I ask you the questions I mentioned earlier, let me summarize what you’ve told me so far, and see if I’ve missed anything impor- tant. You have decided to stop drinking because you have experienced your third DUI and have faced some sti penalties. You also imagine that life will be much di erent, in a good way, if you are successful in making that change in your drinking.”

Although not as detailed as the collecting summary, this MI-consistent summary is a true summary in that it brings together two or more distinct ideas expressed by the client. It is MI-consistent because it does not seek to judge or label the client, but rather to emphasize those elements of what the client has said that will help promote change.

Foundational Concepts and Skills 35

Quick Reference
Basic Motivational Interviewing Skills

Use open questions to invite discussion.
elicit, look for, comment on, and a rm client strengths and successes. Intentionally use simple and complex re ections to expand the change

discussion.
Deliberately use collecting, linking, and transition summaries to talk about

change.

CHANGE TALK AND SUSTAIN TALK

Because a major focus of MI is helping clients explore their own reasons for making a particular change, the MI-consistent provider selectively listens for and re ects client utterances that favor change—change talk. Miller and Rollnick (2013) outlined four components of motivation that are re ected in change talk: (1) wanting to change; (2) perceived ability to change; (3) identi ed reasons to change; and (4) importance of that change. Change talk has been classi ed into two categories—preparatory change talk and mobilizing change talk (Miller & Rollnick, 2013). Preparatory change talk includes statements that communicate the client is thinking about changing yet the statements by them- selves do not predict client action (Amrhein et al., 2003; Carcone et al., 2013). is type of change talk is represented by the acronym DARn (Desire, Ability, Reasons, and Need).

Examples of Preparatory Change Talk

Desire

We o en emphasize that desire statements are valuable because really wanting something to be di erent is important for a client to increase their willingness to act on it. In fact, wanting, wishing, or desire to change is a major component of motivation (Miller & Rollnick, 2013). Desire statements may include:

I wish my health was better.
I’d like to be calm when I drive.
I want to go out with my friends and make healthy eating choices.
I want to leave the house without having to check the lock 10 times.

Ability

Client expressions of what they can do or have done before are valuable state- ments about the client’s perceived ability to change What better way is there

 

36 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

to help clients identify solutions to a problem than hearing and re ecting their statements about what they can do or have done in the past? us, ability state- ments are important as they communicate what clients have done and what they are likely willing to do to change. Ability statements may include:

I could probably use a designated driver more o en.
I may be able to go for a 10-minute walk each evening.
I can get a pill box to sort my medications.
I might be able to brush my teeth rst thing in the morning.

Reasons

A common form of change talk o en expressed by clients is the reasons to change. It is key to elicit and understand why it is important that a client changes because it is the client’s reasons, not others’, that will facilitate client change and are essential in MI. Reason statements o en communicate an “if…then” mes- sage. Reason statements may include:

If I paid attention more to my son he wouldn’t get into as much trouble. It seems like I will have more energy if I get more sleep.
I want to be able to enjoy things again.
By not smoking I would save money.

By talking more to people I might get more friends.

Need

Clients’ statements that express the importance of the change re ect how neces- sary and urgent it is. Miller and Rollnick (2013) highlight that need statements do not include why the change is important and if they did, the statement would re ect a reason and not a need. need statements may include:

I need to do something about my anxiety.
I’ve got to stay out of trouble for the rest of the year.
I must lower my blood pressure.
I can’t keep gaining weight.
I have to get out of the house and socialize more o en.

Quick Reference Change Talk

Desire: I want to change something. Ability: I can do this to change.
Reason: If I change then this will happen. need: I have to change.

 

Foundational Concepts and Skills 37

Mobilizing Change Talk

Mobilizing change talk, or mobilizing statements, include client statements that communicate their commitment to and willingness to change and/or the steps they are taking already to change. is type of change talk can be thought of using the acronym CAT (Commitment, Activating, and Taking Steps) (Miller & Rollnick, 2013). Commitment statements are those that express some level of intention to make a change and are most predictive of change (Ajzen & Albarracin, 2007; Amrhein et al., 2003). Clients may express varying levels of intention to change ranging from a very low level (“I might try it.”) to a very high level (“I’m de nitely going to do it!”). Some clients will discuss the steps they are making to prepare for change. is has been referred to as “activating change talk” (Miller & Rollnick, 2013). Finally, some clients will discuss things they have already done to change. Statements about steps the client has already taken are called taking steps (Miller & Rollnick, 2013). Samples of mobilizing statements may include:

Commitment

I guess I could try eating whole wheat toast for breakfast.
I will probably increase my walking to 5,000 steps a day.
I am not going to smoke in the car or during the middle of the night. I am never going to drink again.

Activating

I will call the job center to see when I can have an appointment.
I plan to buy a pedometer tomorrow.
My wife and I plan to talk about how to help our son meet his probation requirements.
I got some information about di erent social clubs in town.

Taking Steps

I got rid of all of the alcohol in house.
I am now only smoking outside.
I bought some fruit at the store yesterday. I met with the job coach yesterday.

Quick Reference Mobilizing Talk

Commitment: I intend to do this. Activating: I am going to do these things. Taking steps: I did this.

 

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Eliciting and Responding to Change Talk

The focus on eliciting and responding to change talk is arguably the aspect of MI that makes it most distinct from other counseling approaches and communication styles (Houck, Moyers, & Tesche, 2013; Westra & Aviram, 2013). When practicing MI, providers respond with interest in client change talk both non-verbally and verbally because provider behaviors have been linked with client change talk (glynn & Moyers, 2010). Providers can use reflections, questions, affirmations and summaries to elicit and reinforce change talk.

Questions to elicit change talk: “What might you need to do di erently about your diabetes?”

Asking for elaboration: “Tell me more about that.”
Re ecting change talk: “It’s not good, you think, for you to get as drunk as

you do.”
Summarizing change talk: “What you seem to be saying here is that there are

several reasons you need to change your eating: to feel better, have more

energy, and to be a better model for your children.”
A rming change talk: “It sounds like you have thought about this for some

time and know you need to do something about your depression.”

SUSTAIN TALK AND DISCORD

Related to the righting re ex mentioned earlier is sustain talk and discord. Change talk is client speech in favor of change, whereas sustain talk is client speech expressing desire, reason, and need to remain the same and perceived inability to change (Miller & Rollnick, 2013). In other words, when articulating sustain talk, clients are telling you why they should not change.

Sustain Talk Example

Client Statements:

Desire: “I want to keep eating the way I do now.”
Ability: “I can’t turn down a bu et.”
Reason: “All of my friends eat the same way I do.”
need: “I don’t need to change my diet.”
MI-Inconsistent: “Well you have gained 20 pounds in the past 6 months.”

is is MI-inconsistent because it is a confrontational argument for change. Statements such are this are likely to engender discord between providers and clients. Further, the client is more likely to discuss why the provider is

Foundational Concepts and Skills 39

wrong in her response, thus becoming more entrenched in staying the way he or she is.

Somewhat MI-Consistent: “Why might you want to change your eating now?”

is response is somewhat MI-consistent as it is an open question that intends to elicit change talk (i.e., reasons to make a change). However, as a response to sustain talk this question is less MI-consistent as it might engender discord and increase sustain talk. More speci cally, this question dismisses client sus- tain talk and communicates the provider has taken sides with change.

MI-Consistent:

Simple re ection: “Your eating is not a concern for you right now.”

Ampli ed re ection: “ is concern about your weight is an overreaction.”

Double-sided re ection: “Your diet is not of concern to you, and at the same time you chose to come to meet with me.”

Reframing: “It would be di cult for you to make changes to your eating because you like food and it’s an important part of your interactions with friends.”

emphasizing autonomy: “Ultimately, it is up to you what you decide to do or not do about your eating.”

ese responses are MI-consistent because they are less likely to engender discord between providers and clients. In fact, each of them communicates that providers are joining clients where they are at in relation to the area where change is being considered. us, by responding to sustain talk in a MI-consistent way, providers are more likely to engage clients, reduce the discord, and open the door to explore change.

Discord

While sustain talk is client communication about a particular change, say chang- ing a diet, discord is more about the relationship between a provider and client. In other words, discord is a signal that the provider and client are not on the same page and that there may be a ri in the working alliance (Miller & Rollnick, 2013). us, sustain talk and discord should be cues for providers to change their behavior and respond di erently to the client. We o en try to emphasize with those we train that when discord develops it is their responsibility to get “on the same page” with their clients to resolve it. To do this, a provider avoids arguing with the client, listens more carefully, changes direction, and responds to the client in a non-confrontational manner that attempts to change client energy toward discussing positive change (Miller & Rollnick, 2002).

Example: MI-Consistent/Inconsistent Responding to Discord

Client Statement: “Well, I really don’t know why I am here. I was in the wrong place at the wrong time and got an MIP [minor in possession of alcohol].

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I don’t understand why they are so upset; everybody drinks on game day. I came here because the Dean told me to, but I really don’t feel like I should be here, but I want to stay out of trouble. Now I have to come here and hear you lecture me about how I need to change my drinking.”

MI-Inconsistent: “If the Dean is concerned enough to ask you to come here, you must have a problem with your drinking.”

is statement is MI-inconsistent because it directly argues with the client in favor of change. is statement is likely to engender increased discord and will place the client in a position to defend him- or herself and explain why his or her drinking does not need to change. not only is the client not talking about change based on this response, the client will be less engaged.

Somewhat MI-Consistent: “If you’d like, I can provide you with more infor- mation about the rationale behind the alcohol policy.”

is response is somewhat MI-consistent. e provider is asking permis- sion to provide information to address the client’s statement that she does not understand why she has been referred for help. Although asking per- mission to give information is an MI-consistent strategy, in this case it is unlikely that the client’s concern is really that she does not understand the alcohol policy. It is more likely that she is frustrated and feels singled out. us this response is unlikely to decrease discord.

MI-Consistent:
Apologizing: “I’m sorry you were not given clear information about the

policies.”
Simple re ection: “It seems like you and the Dean have a di erent view of the

situation.”
Ampli ed re ection: “ e University is really overacting here about your

drinking given that all college students drink.”
Double-sided re ection: “You really don’t feel like you need to be here and at

the same time you want to learn how to stay out of trouble.”

A rmation: “You have really thought through this situation.”

Shi ing focus: “You are concerned I’m going to force something upon you. I don’t know enough about you yet to even start talking about what makes sense for you to do. I’d like to discuss your thoughts about what brought you here a bit.”

emphasizing autonomy: “You feel forced to come here and I’d like you to know that it is your choice what to do with the information we discuss in this program.”

All of these statements would be more likely to reduce discord between providers and clients as they communicate “I appreciate your situation and don’t want to force you into anything.” Additionally, these statements dem- onstrate a change in direction to avoid increasing discord. Further, the client

Foundational Concepts and Skills 41

may be more likely to respond with change talk, reduced push-back, and more willing to discuss the situation as well as more openness to provider feedback.

Quick Reference
Responding to Sustain Talk and Discord

Re ect client’s concerns about not changing.
A rm the strengths in client’s sustain talk and discord.
Validate client’s concerns and shi the focus of discussion to a less contentious

topic.
explicitly comment on client’s autonomy and personal choice.

CHAPTER SUMMARY

our focus for this chapter was to introduce you to MI and provide a brief overview of the foundational components of this communication approach. In providing this overview we emphasized the importance of adhering to the MI spirit in order to develop pro ciency. It is from the spirit that the MI-consistent use of basic counseling skills such as open questions, a rmations, re ections, and summaries emerge, as well as one’s adherence to the principles of MI. us, if one embraces the spirit of MI it becomes second nature to resist the righting re ex and understand clients’ motivations through listening to and empowering them. Adopting the spirit of MI as part of your philosophy can assist you in intentionally using MI skills and strategies to elicit and reinforce change talk as well as conceptualize and successfully work with sustain talk and discord. We hope that we impressed upon you the importance of adopt- ing the spirit of MI in order to continue on your journey of developing your MI abilities.

 

3

The Four Processes of MI

Recent developments in the evolution of MI have moved away from the two-phase approach to MI (i.e., building motivation and consolidating com- mitment; Miller & Rollnick, 2002) toward four overlapping processes that make up MI-consistent interactions. e four processes are engaging, focus- ing, evoking, and planning. While the processes build on each other, they are not exclusive; there is not a de ned beginning and end to each process (Miller & Rollnick, 2013). In other words, once a client is engaged, that does not mean providers can stop attending to client engagement. e conceptual- ization of the processes that unfold during a motivational interview has gotten more detailed to enhance clarity about what exactly occurs during a motiva- tional interview. However, in our experience, the actual practice of MI has not changed. e portion of an MI session formerly termed “building motiva- tion for change” encompassed the engaging, focusing, and evoking processes. Similarly, the portion of an MI session formerly termed “consolidating com- mitment to change” largely comprised what is now termed planning. In fact the MI-based interventions we have developed map on to the four phases quite well even though they were designed prior to the rede nition. e decision to rede ne the two-phase approach into four processes helps to better clarify the nuances involved in a MI session (such as engaging and focusing) that were not captured by the two phases. is new approach also has promise to help providers utilize MI more e ectively.

ENGAGING

e main focus in the engaging process is on developing the solid work- ing relationship with clients that is important to most clinical encounters (Horvath, 2001). To do this, a provider must be aware of the importance that rst impressions have on clients and be mindful of how provider actions in u- ence others. In particular, providers must be cognizant of how their actions a ect the perceptions and willingness of clients to enter into a working rela- tionship with them. Helping clients feel welcome, comfortable, and safe to

e Four Processes of MI 43

explore their questions and concerns about change are important goals of engaging. To be MI-consistent in engaging requires avoiding traps such as those outlined in the quick reference box (Miller & Rollnick, 2002). All of these are traps because they may lead clients to feel less welcome and safe in the relationship with a provider.

Quick Reference Traps to Avoid

Question and answer: Asking too many closed questions. Premature focus: narrowing in too quickly on what to change. Taking sides: Identifying the problem and prescribing a solution. expert: Communicating that you have all of the answers.

engaging clients is vital to MI and is foundational to the other MI processes and outcomes (Boardman, Catley, grobe, Little, & Ahluwalia, 2006; Catley et al., 2006; Moyers et al., 2005; Murphy, Linehan, Reyner, Musser, & Ta , 2012). us, an MI-consistent provider is always vigilant to engagement and signs of disengagement. ese signs of disengagement may include the cli- ent providing short or vague responses, passively agreeing with suggestions, a closed body posture, changing the topic, interrupting the provider, or simply not saying anything.

Miller and Rollnick (2013) suggest that to appropriately engage someone in an MI interaction requires using a person-centered style that is welcoming, accepting, and genuinely focused on wanting to understand clients’ concerns or problems as well as their values and goals. is requires focus on the person and listening as opposed to determining the root of the problem and the solu- tion—remember in MI that is not the provider’s job. ink of an experience you had with a helper that made it di cult for you to trust them. What was it about that experience or the person’s behavior that made it hard for you to trust them? Were you open to their help or suggestions? Would you go back? ese are thoughts that clients have when they rst meet a provider and are things all providers should be mindful of to be MI-consistent.

Quick Reference
Motivational Interviewing Training Tip: Signs of Disengagement

Signs of disengagement may include the client providing short or vague responses, passively agreeing with your suggestions, a closed body posture, changing the topic, interrupting you, or simply not saying anything.

   

44 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

MI-Consistent Strategies for Engaging Clients

OARS

Use of the most basic strategies in MI, oARS (open questions, a rmations, re ections, and summaries), can be very valuable during the engaging pro- cess. ese are some examples of the use of each type of oARS utterance for engaging:

MI-Consistent Engaging Open Questions

“How are you?”
“What are your thoughts about being here today?”
“In your mind what does our work together look like?” “What are your doubts/concerns about being here?”

MI-Consistent Engaging Affirmations

“ ank you for coming in today. A lot of clients cancel on rainy days.”
“It is good to see you again. It is impressive how much you are sticking with this.” “Looks like you have been making progress.”
“It couldn’t have been easy to make it here today and shows your perseverance.”

MI-Consistent Engaging Reflections

Client: [looks at watch]/Provider: “ e wait was a bit long today.”
Client: “Are my results in?”/Provider: “You’re anxious to get your test results.” Client: “How long will this take?”/Provider: “You’re in a hurry.”

MI-Consistent Engaging Summaries

“So you are really sticking with this and making progress. You made it in even though it was raining, you were in a hurry, and the wait was longer than usual. Let’s go ahead and jump into those test results.”

Exploring Goals and Values

Developing an appreciation for a client is an important aspect of an MI-consistent approach. one way to appreciate clients and their situations is to learn about their goals and values. Before a provider and client can discuss changing, it is impor- tant for the provider to understand the context that led the client to seek help and to consider personal change. exploring goals and values is an interactive process where the provider guides the client through visualizing and articulat- ing various objectives related to the positive changes they seek. Similarly, explor- ing values involves the clari cation of the client’s personal values, or aspects of life that the client nds particularly important. Clients are much more likely to work towards a goal that is valued. erefore, making the connection between clients’ articulated goals and values can be critical in their level of engagement and building motivation for change.

e Four Processes of MI 45

Common Phrases/Statements in this Strategy

exploring goals and values can be introduced to the client in an open-ended interview format. Most o en, a provider starts with broad, open-ended ques- tions like, “How would you like your life to be ve years from now?” or, “What things are most important to you?” ese questions will begin the process of engaging and exploration and can lead the client to think about change at a high level. e order in which the client discusses their di erent values helps the provider better understand their relative importance to the client. As cli- ents begin to explore goals and values, re ections of feelings and restatements can be bene cial in prompting the client to elaborate on or move forward with a train of thought (for example, “So having nancial stability for your children is very important to you,” or, “You seem a little uncertain about your ability to order a salad instead of something fried when eating out.”) is also serves to con rm goals and values with the client, allowing them to give the feedback to the provider concerning how well their goals and values are being understood.

Motivational Interviewing Trainer Tip: Indications that You Are Doing MI-Consistent Engaging

You spend the rst few moments (or as long as it takes) getting to know the cli- ent and putting him or her at ease rather than jumping straight to “business.”

e client will seem to feel comfortable talking to you! You will feel comfortable talking to the client.
You and the client are working together.
You will be asking open, not closed questions.

You will be re ecting what you hear the client say.
You are developing an understanding of your clients and their concerns!

FOCUSING

Although a motivational interview should not proceed until a client has been engaged, MI is much more than engaging a client and creating a safe environ- ment for the client to discuss his or her concerns. MI, like many evidence-based approaches to behavior change, is focused on helping clients make changes that solve the problems or address the concerns that led them to seek services. Providing MI involves focusing on what needs to change—the change target. us, the MI-consistent provider guides the client to identify what he or she wants to change and avoids prescribing or forcing a particular focus. Miller and Rollnick (2013) suggest that focusing helps to identify the client’s change agenda. Table 3.1 provides several examples of MI-consistent questions that can be used to help clients focusing on change targets.

 

46 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

MI-Consistent Focusing Strategies

Table 3.1. MI-Consistent Focusing Questions

Question

Why MI-Consistent

What changes might you like to make?

What is worrying you most about

?

ese questions can center clients on why they are seeing you, and build rapport.

What concerns you most about changing your ?

is question can help providers better understand the client’s attitude, behavior, and where the problem lies for them.

What exactly happens when you try to ?

Questions like this can help providers better understand the client’s concerns, including potential barriers and resources.

What did you rst notice about ?

Questions like this can be helpful in guiding the client to share their expertise about their experience.

Agenda Setting

Agenda setting is a good strategy for avoiding the premature focus trap. MI-consistent agenda setting involves a brief discussion with a client during which the client assumes as much decision-making freedom as possible. is helps the provider and client determine what topics are important to discuss (Rollnick, Miller, & Butler, 2008). A client’s willingness to listen to a provider’s ideas increases when the provider listens and attempts to truly understand the client’s view of the situation rather than focusing solely on their own concerns (Mason & Butler, 2010). However, depending on professional discipline and the practice environ- ment, providers may have information they must deliver or topics they must to dis- cuss. For instance, through training dieticians, we learned that they o en receive orders from a physician to provide nutrition education, such as a heart-healthy diet for a patient who recently had a heart attack. ese trainees would ask us “How can we allow the client to help set the agenda when we have a speci c task to complete?” our response to this question was that although these requirements may in uence the nature of MI-consistent agenda setting, they do not preclude the possibility of MI-consistent agenda setting. We encouraged the dieticians to use a guiding style and look at agenda setting as a shared and collaborative process. As a good guide, it is important for the dieticians to share the doctor’s concerns and recom- mendations and to invite the client to express his or her own concerns during the agenda-setting process. Agenda setting can be used at various times throughout a motivational interview when a provider wants to engage the client in active deci- sion making about the direction the interview will take.

                                                                                                                                                                               

Systolic Blood Pressure

Diastolic Blood Pressure

< 80 mmHg

Waist Circumference (inches)

Men < 40 Women < 35

Body Mass Index

18.5–24.9 Varies Varies
< 200 mg/dL < 100 mg/dL

Weight

Height

Total Cholesterol

LDL (Bad) Cholesterol

HDL (good) Cholesterol

Men > 40 mg/dL Women > 50 mg/dL

Healthy Range < 120 mmHg

1st numbers

2nd numbers

3rd numbers

4th numbers

5th numbers

6th numbers

7th numbers

Table 3.2. Sample Feedback Form for Agenda Setting Know Your numbers Card

(continued)

         

                                                                                                                                                                    

Blood glucose

Pre-meal glucose: 70–130 mg/dL

Diet: Fruits & Vegetables

4–5 cups

Diet: Fiber Diet: Sugar

≥ 25g/day

Diet: Calcium

1,000 mg/day 2 to 3 cups Y/n and I.D.S.

Diet: Dairy

Med: Blood Pressure

Med: Blood Sugar Med: Cholesterol

Y/n and I.D.S. Y/n and I.D.S.

Healthy Range

1st numbers

2nd numbers

3rd numbers

4th numbers

5th numbers

6th numbers

7th numbers

Post-meal glucose:
< 180 mg/dL

~2 tsp/day (5 tbs/week)

Table 3.2. ConTInUeD
Know Your numbers Card

         

e Four Processes of MI 49

Examples of Agenda Setting

“At this time, if it is okay with you, I’d like for us to take a look at the results from some of the questionnaires you completed last time we met. How does that sound? [Waits for client response]. As you can see from this form, there are several things we can discuss. What, among this information, would you be most interested in hearing rst?”

“What would be most helpful for us to discuss rst?”

“Given that your physician has asked me to do so, I’d like to discuss your exer- cise at some point today, but I also wonder what you’d most like to learn about.”

You can also use an assessment feedback form to assist you in setting an agenda. An example of a feedback form called the “Know Your numbers” card that my colleagues and I (MM) used in Hub City Steps—a healthy life- style intervention—is provided as an example (see Table 3.2) (Zoellner et al., 2011; 2014). is form was tailored to meet the needs of the project and focused on health indicators. A form such as this can be adapted to meet various assessment and behaviors. Providers can use the card in agenda setting similar to this:

“ is is what we call your Know Your Numbers card. is card will be lled in each time you come back here. In looking at this card you will see it has information about your blood pressure….[go through sections, cholesterol, etc.] and info about where your score falls in terms of health. In reviewing these di erent areas, we looked at what would seem most important for you to discuss. Among these things, which do you think is most important for you to learn aboutwhat’s next

Motivational Interviewing Trainer Tip: Indications that You Are Doing MI-Consistent Focusing

Your clients have had a major role in developing the agenda for your conversa- tions with them.

You have a good understanding of your clients’ goals.
You recognize how consistent or di erent the goals are between you and your

clients.
You and your clients are working together toward shared goals.

EVOKING

Traditionally, what has been described as MI can be seen in the process of evoca- tion. A er a focus for change has been identi ed, the MI-consistent provider elic- its from clients their own reasons for wanting or needing to make the particular

 

50 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

change—“change talk.” It is this eliciting from clients that helps them identify and appreciate their own motivations for changing. In essence, the individual is talking him- or herself into changing. e expert MI provider will generally elicit multiple motivations (remember DARn [preparatory]-CAT [mobilizing] change talk from chapter 2) for change prior to proceeding with planning. expert MI providers also generally seek to elicit change talk that focuses not only on the history of the problem, circumstance, or behavior, but also on how change (or lack thereof) might in uence the present or future for a client (Moyers, Martin, Manuel, Miller, & ernst, 2010). Conversely, the MI-inconsistent provider will lecture clients about why it is important or why clients need to change. is o en counterproductive e ort may actually reduce motivation and increase discord, particularly when clients are ambivalent (Miller & Rollnick, 2013).

It is important to note that the process of evoking will vary from session to session depending on the motivators for change that are most salient to a par- ticular client. Furthermore, in keeping with the spirit of collaboration described in chapter 2, it is always essential that a provider use information and feedback from the client to guide the ow of an MI session. nonetheless, in our work as providers and supervisors of MI, we have found a pattern that commonly emerges during a well-done evocation process. Usually, it seems most natural for providers and clients to focus rst on negative consequences or problems a client has encountered as a result of the problematic behavior or life circum- stance about which change is being considered. In fact, o en when a provider asks: “What brings you in today?” the client will spontaneously respond with one or more negative consequences that he or she has experienced related to the change being considered. For example: “My weight has gotten over 200 pounds and none of my clothes t any more,” or “I got my third DUI [driving under the in uence] and my attorney said that if I didn’t come to treatment I’d probably do some jail time.” A er the negative consequences or problems have been explored and elaborated, a provider will o en elicit anticipated outcomes of making the change or not making the change. For example, the provider might ask, “If you are successful in losing 25 pounds, how do you think your life would be better?” or “What concerns, if any, do you have about what could happen if you continue to drink and drive?”

MI-Consistent Evoking Strategies

Questions to Elicit Desire, Ability, Reasons, and Need (DARN Talk)
Desire
“What do you want (like, wish, hope) will be di erent?”

“Why might you want to make this change?”

Ability

“What is possible for you to do?” “What can/could you do?”

e Four Processes of MI 51

“What are you able to do?”
“If you decided to make this change, how would you do it?”

Reason

“What would be some speci c bene ts?”
“What risks would you like to decrease?”
“What are the three most important bene ts you see from making this change?”

Need

“How important is this change?”
“How much do you need to make this change?”

Beware of MI-Inconsistent Questions

It is important to be intentional in the selection of evoking questions. e ques- tions that seem to come most naturally to many of those we have trained (and presumably came most naturally to us before all of these years of MI practice and training) are questions that elicit the opposite of change talk: sustain talk. As described in chapter 2, sustain talk refers to utterances that support staying the same: Why the client does not want to change. Why the client perceives he or she can’t change. Reasons the client believes he or she should stay the same. e questions that elicit these utterances from a client are things like, “Why don’t you…?” or “Why can’t you…?” or “Why won’t you…?”

Readiness Ruler/Scaling Questions

Using a readiness ruler or rating scale can be helpful for eliciting subjective reports of motivation from clients (Lane & Rollnick, 2009). To assess readiness for change, an Importance-Con dence Scale ranging from 0 (not at all impor- tant/con dent) to 10 (extremely important/con dent) can assist in describing the client’s developing motivation and may elicit change talk by providing a helpful perspective about the client’s personal dilemma surrounding the desired change. Although verbal forms of the rating scale are commonly used, using visual forms, such as drawing a line with numbers marked 1 to 10, can also demonstrate scal- ing questions. (A sample readiness ruler handout is provided in chapter 7.) e choice of stem for the readiness ruler/scaling questions (e.g., “How important is it to you…?” “How con dent are you…?” “How committed are you…?”) will determine which dimensions of readiness for change you assess.

For instance, you can ask the client:

“How strongly do you feel about wanting to protect yourself when drinking? On a scale from 1 to 10, where 1 is ‘not at all,’ and 10 is ‘very much,’ where would you place yourself now?”

You can also assess the importance that the client places on a particular behavior:

52 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

“How important would you say it is for you to increase your safe sex practices? On a scale from 1 to 10, where 1 is ‘not at all important,’ and 10 is ‘extremely important,’ what would you say?”

is type of questioning can also be used to assess how con dent or certain the client is in his or her ability to make a change.

Assessing con dence through scaling questions may be accomplished by asking:

“On a scale from 1 to 10, where 1 is ‘I’m certain that I could not,’ and 10 is ‘I’m certain that I could,’ how con dent are you that you could engage in pleasur- able activities?”

Particularly near the end of an encounter, this type of question can also be used to assess a client’s commitment to change, as in the following example:

“On a scale from 1 to 10, where 1 is ‘not at all,’ and 10 is ‘couldn’t possibly be more,’ how committed are you to your plan for walking 4 days per week?”

A key component of using the readiness rulers/scaling questions is question- ing clients about why they rated themselves a particular number. When using scaling questions, one very useful follow-up is to ask what makes the number what it is and not a di erent number. is answer provides perspective on how and why change is important for the client. Typically, it should be asked why the client’s selected score is higher than a lower number, because it elicits more reasons for changing (e.g., “What makes it an 8 and not a 5?”). A provider might also wish to ask the client what it would take to move him or her to a higher number (e.g., “What would it take to move you from a 5 to an 8?”). When it follows an importance ruler, this question creates an opportunity for the client to consider potentially undesired consequences of not making a change (e.g., “I guess if I had another heart attack I’d have to get serious about exercise.”). When it follows a con dence ruler, this question o en provides valuable infor- mation the provider and client can use in formulating a plan for change (e.g., “I think if I knew my family would support me, I’d feel more con dent about quitting smoking.”). Without these follow-up questions, a readiness ruler/scal- ing question may still provide valuable information about a client’s level of readiness for change, but represents an important missed opportunity to evoke change talk.

Beware of Follow-up Questions that Evoke Sustain Talk

As with the MI-consistent evoking questions described earlier, we have found that for many of those we train, the follow-up question that comes most natu- rally is most helpful for eliciting sustain talk or defensiveness. For example, if a provider asks, “on a scale from 1 to 10, how important is it for you to take your medication daily?” and the client responds “5,” and the provider follows up with “Why are you at a 5 and not a 10?” it is almost impossible for the client to answer

e Four Processes of MI 53

with anything other than sustain talk (e.g., “I just can’t make it a priority now because I have too many other things going on.”). A client may also perceive an air of judgment in such a question (i.e., that the provider believes he or she should nd it more important) and thus responds defensively. Defensive answers or answers that the client believes you want to hear also arise if rapport is poor. erefore, good rapport and a guiding communication style more accurately assess a client’s motivation for change.

Decisional Balance

e pros/cons decisional balance allows a provider and client to fully consider change by think through positives and negatives of both changing and not chang- ing (Ingersoll et al., 2002). is strategy is typically used when clients are ambiv- alent about making a change in their life. is strategy helps a provider guide clients in making a decision about change. e decisional balance exercise can be introduced with provision of information about the concepts of motivation and ambivalence.

For example, a provider might say something along the lines of:

Because most of the things we choose to do have both positive and negative aspects about them, we o en experience ambivalence when we consider changing. Ambivalence means you have mixed feelings about the same matter, and those di erent feelings are con icting with each other. You want to do something and at the same time you don’t want to do it. When people are ambivalent, it is di cult to make decisions because it appears that nothing they do will meet all of their desires. One way to work through this is to look at both sides of the coin by examining both sides of our feel- ings at the time.” A sample decisional balance worksheet is presented in chapter 7.

Motivational Interviewing Trainer Tip: Indications that You Are Doing MI-Consistent Evoking

You have heard at least one and preferably several of your clients’ motivations for changing.

You have a sense of how important change is to your clients.
You have a sense of how con dent your clients are about change.
You are hearing and responding to change talk.
You are using questions and re ections to draw out change talk versus providing

change reasons.
You are not the one arguing for change.

 

54 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

PLANNING

Developing a specific plan for change and commitment to that plan are important to guiding the client toward change. Consistent with the spirit of MI, the planning process should focus on eliciting change ideas, options, and solutions from clients versus prescribing or directing clients in how to change. This is an important point. In our experience, those we train often think that once the motivation for change is “secured” that they now have permission to be directive and “tell” clients how to change. However, to remain MI-consistent, a provider must continue to recognize that clients are experts on their own lives and as such tend to have at least some, if not all, of the solutions to their problems within themselves (Miller & Rollnick, 2013). Thus, the focus at the planning stage should be drawing these solutions out from clients and supplementing them with information the provider has about what has helped others in similar situations, what options are available to the client, or what the provider would recommend (only when necessary or when requested by the client). By doing so, the provider not only helps the client identify a solution that is the best fit for him or her, but also increases the chances that the client will commit to the solution. Think about it for a moment. Who knows you better than you know yourself? It is unlikely that we could provide a better method for you to read this book than you could develop on your own. We can make suggestions, but ultimately, you will read this book in a way that is best for you. This same principle applies to chang- ing. As professionals, we all have education and experience with methods for changing a problem behavior. However, we do not know how these methods may or may not work for each and every client, but the client knows what will be more likely to work. We can facilitate a planning discussion through skillful use of questions, reflections, providing information and options, and summarizing.

MI-Consistent Planning Strategies

Questions

“What do you think you’ll do?”
“What would be a rst step for you?” “What, if anything, do you plan to do?” “What do you intend to do?”

Exchanging Information

o en during change planning, a client may ask or a provider may feel com- pelled to provide information about change options. What makes information exchange MI-consistent or MI-inconsistent is the way in which the information

e Four Processes of MI 55

is presented. Traditionally, the information exchange process has been an expert–recipient approach where the “expert” shares and interprets the informa- tion. is is an MI-inconsistent approach to providing information as it neglects the client’s interpretation of the information, focuses on prescribing information versus eliciting and fosters passivity in clients. An MI-consistent approach to providing information facilitates a collaborative and engaging method in which the client is asked to interpret the information.

one process to provide information in an MI-consistent way is to use the elicit-provide-elicit approach, which is a cyclical process of guiding clients through information exchange (Lane & Rollnick, 2009; Rollnick et al., 2008). In this process, the provider elicits from the client before providing information. For instance, in sharing information about diabetes, a provider might rst ask, “What do you know about diabetes?” e client’s answer to this question will help the provider better understand what information the client currently pos- sesses, including what is accurate or inaccurate, and better focus the information o ered. Following this eliciting the provider o ers a small chunk of information about diabetes. A er giving some information, the provider asks about the cli- ent’s understanding/interpretation or reaction to the information. is informa- tion exchange process can be very valuable when providing assessment results or sharing a diagnosis.

Example of Elicit-Provide-Elicit:

Initial eliciting questions:

You have discussed several concerns related to your alcohol use and said things have to change and you are going to do something about it. What would you like to learn most about or discuss in relation to changing?”

Client response:

“All I’ve heard from people is that to change you have to go to rehab and spend a lot of time away from work and family.”

Provide information in manageable chunks and focus on the data and not your interpretation:

“You have heard some things about what it takes to change one’s drinking behavior and are concerned about that. If I might share some information to add to your understanding, people make changes in di erent ways. Some people change on their own; some go to a 12-step group, while others engage in outpatient counseling services. And yes, some people do go to a facility for intensive treatment. Based on the information you gave us about your alcohol use compared to national criteria it seems like outpatient counsel- ing may be the most appropriate place for you to address your drinking concerns.”

Follow-up eliciting question:

“What do you make of this information?”

56 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

Discussing a Menu of Options

Presenting a menu of options is an approach to engaging clients in the planning process. With this approach the provider invites clients to choose the change strategies that seem best for them from a set of options the provider has prepared based on his or her expertise, best practice guidelines, etc. At the same time, when using this strategy in a fully MI-consistent fashion, the provider also encourages clients to include change ideas that may not be in the prepared set. For instance, in the following example, which might be used with college students, the menu has safe drinking behaviors that have been shown to reduce alcohol-related con- sequences. note that there are open bubbles on the options sheet that would allow the client to add additional ideas they are willing to consider or are already doing. When helping the client identify a behavior change strategy the provider can open the conversation about change options using the menu (see Figure 3.1).

Sample Menu of Options

“If you’d like we can talk about some strategies you might use when drinking to reduce the risk of negative consequences. Here is a sheet that includes some behaviors that other college students from your university use to protect them- selves when drinking. is area represents putting planned limits on drinking (the “know your limits” picture). is area represents mixing alcoholic and

Protective Strategy Options

          

?

?

?

   

Figure 3.1 Sample Menu of options for Safe Drinking Strategies

e Four Processes of MI 57

non-alcoholic beverages (picture of water). is area represents the manner in which you drink (the beer cups—representing beer pong). ese areas repre- sent reducing the potential for serious harm (the glass and key and the “who’s watching your drink”). You will also notice some empty areas. ese represent your ideas that are not represented by the other areas. Based on the drinking goals you mentioned before, which of these strategies, if any, might you use to protect yourself when drinking yet meets your goals?”

Developing a Plan for Change

e change plan is a concrete road map that the participant can follow in order to reach their change goals (naar King & Suarez, 2011). To be e ective, the change plan speci cally outlines the (1) behavior to be changed, (2) remind- ers of the motivational factors, (3) change goals, (4) action plan, in manageable steps in order toward change, (5) potential barriers, and (6) steps to overcome those barriers. Typically the change plan is implemented when someone is ready for behavioral action. us, the change plan will be negotiated a er enhancing motivation and commitment to make behavioral change.

Common phrases/statements that are used in this strategy:

“Now that we have discussed some aspects of your diet and exercise, what do you think you want to do about your eating and exercise?”

“Now that we have come this far, I wonder what you plan to do?” Table 3.3. Components of Developing a Change Plan

Planning Goal

MI-Consistent Question

Important Points to Consider

Identify the changes the client wants to make.

“What might be some of the changes you want to make in your health?”

It is important to be speci c and include goals that are positive (e.g., wanting to increase exercise, eat more fruits and veggies) and not just negative goals (e.g., stop eating fried foods).

Highlight the reasons to change.

“We discussed several reasons for changing earlier such as [summarize a few points]. For you, what are some of the most important reasons you want to change?”

Important to elicit/ remind the client of the reasons the client previous provided.

(continued)

Tabel3.3. ConTInUeD

Planning Goal

MI-Consistent Question

Important Points to Consider

eliciting why the client wants to change—the change goals.

“Tell me about your overall goals or what you hope you will achieve by making these changes.”

goals should be realistic and achievable.

Identifying what the client plans to do to change.

“ ere are a lot of things you can do to work toward your goals—what are some of the activities you think you will do to work toward your goals?”

Information and options—presented in an MI-consistent fashion— can help.

eliciting reasonable rst steps.

“of those activities, what do you think you can do rst?”

“In making some of these changes, what are some of the rst steps?”

“When, where and how will these steps be taken?”

It is important to elicit speci c, concrete steps.

What can interfere or derail the plan?

“Sometimes it helps to think of the things that may get in the way of your plan.”

“What could interfere with this plan and how can you stick to the plan?”

Remain positive and focus on identifying how to sidestep this interference.

Identify who can help the client maintain the plan.

“Who can support you in keeping to your plan?”

It is important to identify speci c individuals and how they can help.

Identify how the client will know the plan is working.

“How will you know your plan is working?”

Identify speci c, concrete indicators of how the plan is working or not.

e Four Processes of MI 59

Table 3.3 provides some components of change planning and examples of questions to ask clients, as well as important points to consider with each com- ponent. ese components are based on the Change Plan Worksheet developed for Project Match (Miller, Zweben, DiClemente, & Rychtarik, 1992) and revised and used by us in several projects.

Motivational Interviewing Trainer Tip: Indications that You Are Doing MI-Consistent Planning

You are aware of a reasonable next step but not imposing it.
You are resisting the urge to give advice or recommendations until you have

evoked solutions from the client.
You are asking permission when providing information, recommendations, or

advice.
You are genuinely open to idea that the best solution for a particular client may

not be the one you would recommend.

ONE ROAD MAP FOR THE FOUR PROCESSES

As providers begin to attempt to implement MI, one concern that is frequently expressed during early coaching sessions is a lack of con dence in how to navi- gate an MI session. In response to this concern, we have developed a “road map” for a typical MI session that many of the individuals we have trained have found helpful as they begin implementing MI (see Table 3.4). Although the skilled MI provider will rely primarily on information and feedback from a client to guide the ow of an MI session, this road map serves as an aid or crutch for early ses- sions during which the ow of the session is less intuitive. You will note that the primary strategies are open question, re ections, and summaries. Although they may not come as naturally as the questions, it is crucial not to skip the re ections and summaries.

THE FOUR PROCESSES OF MOTIVATIONAL INTERVIEWING: A HEALTH PROMOTION EXAMPLE

one application of MI that we have been involved with is HUB City Steps which was an MI-enhanced nutrition and exercise intervention aimed at reducing hypertension among African Americans. e project involved a three-month intervention where individuals received in person feedback about their health status and developed an individualized change plan (Zoellner et al., 2011; 2014).

 

Table 3.4. Sample Road Map for the Four Processes

engaging

• Ask: How are you doing today?

• Re ect the client’s response

Focusing

• If you have an a priori target behavior, ask permission to focus on it: If it’s okay with you, I’d like to spend a few minutes talking about ____________.

• If you don’t have an a priori target behavior, ask: What brings you here today?

evoking

• Ask: What are the three best reasons for you to ____________?

• Re ect all the reasons you have been given

• Ask: What other reasons might you ____________?

• Re ect the response you are given

• Ask: How do you imagine your life would be di erent if you were successful in ____________?

• Re ect the response you are given

• Ask: On a scale of 1 to 10, how important is it for you to
____________?

• Re ect the response you are given

• Ask: Why is it a ____________ and not a ____________?

• Re ect the response you are given

• Ask: On a scale of 1 to 10, how con dent are you that you can ____________?

• Re ect the response you are given

• Ask: Why is it a ____________ and not a ____________?

• Summarize ALL the reasons for change you have heard (use a double-sided re ection if there is some discussion of reasons for not changing)

Planning

• Ask: What is the next step for you? or What do you think you will do?

• Re ect the response you are given

• Ask: I know we’ve talked about this quite a bit already, but what
would you say are the main reasons you want to make this change?

• Re ect the response you are given

• Ask: What are the steps you plan to take in making this change?

• Re ect the response you are given

• Ask: What are the ways other people can help you make this change?

• Re ect the response you are given

e Four Processes of MI 61

• Ask: How will you know if your plan is working?

• Re ect the response you are given

• Ask: What are some things that could interfere with your plan?

• Re ect the response you are given

• Ask: What will you do if the plan isn’t working?

• Re ect the response you are given

• Summarize eVeRYTHIng you have written on your change plan

• Ask: On a scale of 1 to 10 how committed are you to following this plan?

• Re ect the response you are given

• Ask: Why are you at a ____________ and not a ____________
(lower number)?

• Re ect the response you are given

• Summarize the entire MI session

Trained MI coaches with nutrition or psychology backgrounds conducted the sessions (Madson, Landry, Molaison, Schumacher, & Yadrick, in press). In Table 3.5 we highlight the processes of MI using the MI feedback sessions. is example was adapted from the HUB City Steps MI counselor manual but is not a script (Madson, Bonnell, McMurtry, & noble, unpublished manual).

THE FOUR PROCESSES OF MOTIVATIONAL INTERVIEWING: AN ALCOHOL PREVENTION EXAMPLE

For more than 20 years, the Brief Alcohol Screening and Intervention for College Students (BASICS; Dime , Baer, Kivlahan, & Marlatt, 1999) has been used on college campuses nationwide. e BASICS program is an alcohol prevention program focused on high-risk students with slight yet detectable evidence of alcohol abuse (e.g., evidence of heavy drinking episodes—binge drinking or drinking-related consequences). With a solid grounding in MI, the BASICS program involves a student meeting with a BASICS counselor for two ses- sions. Session one involves an assessment of alcohol use and related problems/ risk associated with use. e second session involves personalized feedback and discussion about assessment results in a manner aimed at facilitating student motivation to better protect them when drinking. Table 3.6 provides an illustra- tion of how the feedback session, as implemented at e University of Southern Mississippi, follows the four processes of MI.

Table 3.5. Health Promotion example of the Four Processes

MI Process

Application to HUB City Steps

engaging

ank participant, engage—obtain reaction to participation in HUB Steps and set the stage for coaching session.

“ ank you for participating in our health fair today. How was your experience with the di erent activities you participated in today? [Re ect client response]. My name is Mike Madson and I am a health counselor for this project. My job with HUB City Steps is to discuss with you some of the information gathered today based on what you think is important and to help you decide what, if anything, you may want to change in relation to your health and how you may go about changing. How does that sound to you?”

[re ect]

Focusing

Agenda setting—to focus discussion on health indicators important to client by introducing Know Your numbers card.

If it is okay with you, I’d like to talk about the results of your assessment today. is is what we call your Know Your Numbers card. is card will be lled in each time you come back here. In looking at this card you will see information about your results and information about where your score falls in terms of health. For example, here is information about your blood pressure and where your score falls within a healthy range. We looked at di erent areas that would seem the most important for you to discuss.”

[Re ect client responses].
What is next most important for you?

Provide feedback about health results and evoke clients’ reasons, need, and ability to change.

Using elicit-Provide-elicit, provide information on participant results and MI-consistent strategies to help participant increase readiness to change.

“You indicated that you are most concerned about your blood pressure. What sort of things do you know about blood pressure? [Re ect client responses]. In looking at your blood pressure today compared to healthy levels, it appears your blood pressure is a bit high. What do you make out of that given what you know about high blood pressure?”

[Re ect client responses].

is process could be repeated for di erent concerns clients have and could be summarized a er.

MI Process

Application to HUB City Steps

evoking

Summarize and elicit.

“You identi ed several factors on your Know Your Numbers card that concerned you. ese included high blood pressure, higher weight than you’d like, and not having as much energy as you’d like.”

[Use MI consistent strategies to elicit]

“How important is it for you to make some changes to your health?”

[re ect]

“What are some of the reasons you might want to change your health?”

[re ect]

“What might your life look like 5 years down the road if you changed/ didn’t change your health?”

[re ect]

“What are some of the good things about your current behavior? What are some of the not-so-good things?”

Planning

Summarize client discussion about change.

“If it is okay with you I would like to summarize what we discussed. You expressed concern about your health, in particular your blood pressure, weight, and limited energy. It is important to you to change some of your eating and health to be a role model for your children. You were a bit uncertain about modifying your diet because you don’t want to disappoint your family by not cooking their favorite foods, and at the same time you recognize how it might be valuable to help your family eat healthier. Also, it is important for you to have more energy, and you indicated how eating healthier and increasing your physical activity would be the best ways for you to become healthier. Given all of this, what do you think you may want to do?”

[re ect]

Present participant with menu of change options

“If you’d like we can talk about some changes you could make to improve your health. To help us, we have the menu of options that other individuals have used to become healthier. Here is a sheet that includes some behaviors that can be important in helping people manage similar concerns to yours. is area represents formal exercise like walking. is area represents increasing physical activity in your daily life, like taking the stairs rather than the elevator. is area represents eating healthier, which may include eating more fruit and vegetables. You will also notice some empty areas. ese represent your ideas that are not represented by the other areas. What, if any, areas here would you wish to talk about, or perhaps there are other things you want to raise that are more important to you in relation to changing?”

(continued)

64 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

Table 3.5. ConTInUeD

MI Process

Application to HUB City Steps

elicit a plan from the participant’s aspects related to a speci c plan. “What is it speci cally that you may want to do?”
[re ect]
“What are your reasons for making this change?”

[re ect]

“What are your goals for making this change?”

[re ect]

“What might be the rst step in your plan?”

[re ect]

“Who might help you reach your goals?”

[re ect]

“What sort of results do you expect from changing?”

[re ect]

Summarize the plan emphasizing the t for the participant (goals, needs, intentions, and beliefs) and evoke commitment.

“Let me see if I am following you. You want to eat more fruits and vegetables and you want to start walking each night a er dinner
for at least 20 minutes. For you, these two changes are important to help you manage your blood pressure, increase your energy, and to
be a healthy role model for your children. e rst step is to look for sales on fruits and vegetables and to get a pair of walking shoes. You indicated that your neighbor will be interested in walking with you and that you will ask her to set up a walking schedule. It is really your hope that by making these changes you will lose some weight, become less winded when walking, and feel better about yourself. Is this a plan you can commit to?”

CHAPTER SUMMARY

By learning more about and focusing on the four phases of a motivational interview, you can better appreciate how to guide clients in a discussion about changing. Many providers we have trained are tempted to jump straight to “planning” and focus an interaction immediately on identifying solutions to clients’ problems. While this may sometimes be an e ective strategy with cli- ents who enter a helping relationship ready, willing, and able to change, it is not likely to be e ective for clients who do not come in with that level of motivation. Understanding your clients, uncovering a shared focus for change, and evoking

Table 3.6. Alcohol Prevention example of the Four Processes

MI Process

Application to BASICS

engaging

engaging in the rst BASICS Session

“Hello, my name is Mike Madson and I’m one of the BASICS counselors. Welcome to the BASICS program. anks for coming
in today. I understand that you were asked to attend the BASICS program by your hall director. However, I would value the opportunity to understand your perspective in relation to why you are here. If you are willing, tell me a little about your perspective on what happened and what you think about having to attend BASICS
.” [re ect what the client has said]

“If it is all right with you I would like to provide some information about the program and what you can expect as well as answer any questions for you. How does that sound? My job is to work with you to gather and discuss some information in relation to your alcohol use. e goal of BASICS is not to determine if you have an alcohol problem or put some label on your drinking. Instead my goal is to talk with you about the information you provide about your drinking, what that information means to you, changes you have already made, and based on what you think is important decide what, if anything, you may want to change in relation to your drinking. How does that sound to you?”

[re ect]
engaging in the feedback BASICS session.

Welcome back. ank you for coming in today. How have you been since our last meeting?”

[re ect]

“Before we begin talking about the information you provided last time we met, I wonder if you had any questions or concerns about our last meeting, or had any reactions to the meeting or the questionnaires you completed.”

[re ect]

“If I might provide some information, you may remember from
our last meeting that the purpose of this meeting is to discuss the information you gave about your alcohol use. It is my hope that we have a collaborative conversation, so please stop me along the way to ask questions or clarify things. Does that sound okay to you?”

[re ect]

(continued)

Table3.6. ConTInUeD

MI Process

Application to BASICS

Focusing

Agenda setting to focus the discussion.

“We have a bunch of things to discuss; are there any things that you are particularly interested in talking about?”

[re ect]

“One place we could begin, if you would like, is to review your self-monitoring form. How does that sound?”

[re ect]

Provide personal assessment feedback using elicit-provide-elicit.

“From your perspective, in what ways, if any, has alcohol gotten
in your way or resulted in unpleasant experiences? Based on the information you provided, it appears that you o en do things when drinking that you later regret. What do you make of that?”

evoking

“People have many di erent reasons for drinking alcohol. What are some of the reasons you drink alcohol? How might that in uence how much you drink or when you decide to stop drinking?”

[re ect]

“Sometimes students decide to engage in strategies when they drink to reduce the negative consequences they experience. How might that t or not with your goals for dinking?”

[re ect]

On a scale of 0 (not important) to 10 (very important), where would you place the importance of learning about new or additional ways to protect yourself from negative consequences when drinking? [Client responds saying 5]. What makes it a 5 and not a 3.”

[re ect]

What may be some of the drawbacks to using safe drinking strategies; what may be some of the bene ts?”

[re ect]

Planning

Summarize to transition to planning

“We started today and you were unsure whether you wanted to make any changes to your drinking. Part of you enjoys drinking the way you are now and you receive enjoyment from partying with your friends. At the same time you learned that your drinking has led to an increase in negative consequences and you have felt increasingly embarrassed by things you have done when drinking. You indicated that you would like to learn some strategies that you can use to reduce the consequences you have experienced when drinking. What, if anything, would you like to do?”

MI Process

Application to BASICS

[re ect]

“If you’d like we can talk about some strategies you might consider using when you drink to reduce the risk of negative consequences. What are some things that come to your mind when we talk about safe drinking?”

[re ect] “Here is a list that includes some behaviors that students at this university and other college students use to protect themselves when drinking. Some students use strategies to control their consumption of alcohol such as avoiding shots or chugging alcohol, or alternating an alcoholic and non-alcoholic drink. Other students use strategies to reduce serious harm associated with drinking such as using a designated driver or knowing what is in their drink. Based on the drinking goals you mentioned before, which of these strategies or others, if any, might you use to protect yourself when drinking yet meet your goals?”

[re ect]
elicit to develop a plan

“For you, knowing what is in your drink and using a designated driver would be strategies you could use when drinking.

What might be your reasons for using those strategies?”

[re ect]

“In using these strategies, what do you hope will happen?”

[re ect]

“Who can help you use these strategies?”

[re ect]

“How will you know these strategies are working?”

[re ect]

“Before we close today I would like to summarize your plan of action to become a safer drinker. For you, reducing the harm associated with drinking is important because you are seeing increasing problems when you drink. You expressed a willingness to become more aware
of what you are drinking and making sure to use a designated driver who has not been drinking. ese steps will help you to better manage your drinking and to make sure you are safe. Your hope is that these strategies will help you drink more responsibly and keep yourself out of trouble and from doing things you later regret. You identi ed your sorority sisters as people who can help you with this plan and that you will inform them of your plan and goals. Is this something you are willing to commit to doing?”

68 MoTIVATIonAL InTeRVIeWIng oVeRVIeW

clients’ motivations for changing are useful for helping clients develop the moti- vation necessary to undertake di cult changes. Many providers we train are also tempted to focus on providing suggestions and giving advice when developing change plans with clients. is may result in a plan that the client cannot or will not follow. Collaboratively developing a change plan in an MI-consistent fashion increases the likelihood that a client’s plan will be successful. our discussion of the processes is simply an overview and readers are encouraged to read Miller and Rollnick (2013) for more detail on the four processes.

PART II

Motivational Interviewing for Clinical Challenges

4

Less Ready to Change

Many of the strategies widely employed by helping professionals assume that cli- ents enter the helping relationship ready to make changes. For example, immedi- ately following an assessment of a client’s smoking behavior, a smoking cessation specialist might describe the various available options for smoking cessation and ask the client to choose one. In this case, the specialist is operating under the assumption that because a client has come to a smoking cessation clinic, he or she is ready to quit smoking. e transtheoretical model (TTM; Prochaska & DiClemente, 1983) and its accompanying stages of readiness to change provide a valuable framework for understanding clients who are less ready to change. As mentioned in chapter 2, the TTM and MI evolved almost simultaneously and they can be used complementary to each other. Whereas MI provides a frame- work for understanding how provider-client interactions can in uence readiness to change, the TTM helps us to conceptualize our clients’ readiness to change based on attitudes, behaviors, and intentions they display according to ve stages. e quick reference provides a description of the ve stages.

Quick Reference
Stages of Readiness to Change

Precontemplation: Not aware a change is needed. Pros of not changing outweigh pros of changing. Avoids talking about change.

Contemplation: More aware of need to change. Recognizes the negatives of not changing. Concerned about behavior.

Preparation: Intending to change. Pros of changing outweigh pros of staying the same. More engaged and making plans to change.

Action: Taking steps to change.
Maintenance: Preventing lapses and relapse a er changing.

Typically, clients who are less ready to change tend to be at the precontem- plation or contemplation stage of readiness to change. In other words, rather than “lacking motivation,” individuals who are less ready to change are o en not aware of the need to change or are considering both the positives and negatives

  

72 MoTIvATIoNAl INTeRvIeWINg FoR ClINICAl ChAlleNges

of changing and not changing. Additionally, clients may be less ready to change when they were not involved in the planning. us, they may be very ready to change, but less ready to implement someone else’s plan. When clients are less ready to change they can show us in di erent ways, including not attending ses- sions, not adhering to treatment, or expressing no need to change (e.g., that they are attending simply to satisfy a mandate or referral). Fortunately, MI is help- ful for working with individuals who are less ready to change. We provide some MI strategies for addressing challenges o en associated with clients who are less ready to change.

CLINICAL CHALLENGE 1: NO-SHOWS

Description

A challenge encountered in almost any setting where MI might be applied to facilitate change is clients who frequently reschedule appointments (o en with little notice) and clients who fail to show for scheduled appointments. ere can be a number of factors that cause clients to miss scheduled appointments (with or without notice to the provider), such as problems with childcare, forgetful- ness, or unexpected events. Whatever the cause, missed appointments undoubt- edly reduce a provider’s ability to help a client make positive changes. Missed appointments can also create systemic problems that reduce the quality of ser- vice providers can o er. For example, just like airlines and hotels, many medi- cal clinics nd it necessary to overbook schedules to compensate for anticipated canceled sessions and no-shows. Who hasn’t been to the physician on a day when everybody scheduled actually shows up? Wait times are o en an hour or longer, those waiting to be seen grow increasingly impatient and frustrated, and pro- viders and o ce sta may feel a need to rush and thus may not o er the same level of care or service they normally would. For these reasons, no-shows are an important clinical challenge to address.

When clients are queried about the reasons for missed appointments, they will provide a range of reasons. For example, De fe, Conklin, smith, and Pool (2010) found psychotherapy clients reported reasons for their missed appoint- ments ranging from symptoms, to practical concerns, to motivational issues, to negative treatment e ects. To providers, these reasons may range from the seem- ingly reasonable (e.g., “the school called to say my son had a fever and I had to pick him up”) to the seemingly absurd (e.g., “my son’s tarantula got out of its cage and I had to nd it before I could leave the house”). Many times, particularly with clients who repeatedly miss or reschedule appointments, a provider may be le wondering whether the reasons provided are truthful, or whether the missed sessions are an indication that the client is not committed to his or her work with the provider. Possibly wondering, “Does this client also miss his appointments at the barber? Does he forget to pick his daughter up from school? Does he blow o social engagements? or does he only do this to me?”

less Ready to Change 73

It is possible that provider mistrust and frustration with no-shows may be exacerbated by a di culty understanding the perspective of the “no-shower.” speaking from personal experience, we can probably collectively count on one hand the number of times we have simply failed to show up for a scheduled appointment or canceled at the last minute. In fact, research on characteristics that have been associated with no-show suggests that individuals who serve as providers in settings where MI might be employed may o en di er in impor- tant ways from their clients who no-show. For example, a study of predictors of no-shows at a community mental health center in Denmark revealed that in addition to clinical- and employment-related characteristics, age below 25 and 9 or fewer years of education were predictors of no-showing (Fenger, Mortensen, Poulsen, & lau, 2011). Although not reported in the study, it is likely that most providers at the center were above age 25 and had 10 or more years of education. e following example illustrates a typical no-show scenario.

example: Mary and her primary care physician have been discussing her weight at annual check-ups for several years. Over that time, Mary has progressed from overweight but generally healthy, to obese with metabolic syndrome, to severely obese with type 2 diabetes. Mary reports that she has repeatedly attempted to lose weight, but always loses only a few pounds and quickly regains them. Mary’s physician believes that successful weight loss is crucial to Mary’s health, and has referred her to a dietician for nutritional counseling. Mary rescheduled her initial visit with the dietician two times, resulting in a delay of almost 3 months between the referral and her initial visit. Since the initial visit, Mary has returned for follow-up only once in the last 6 months, even though she and the dietician agreed to meet monthly to track her progress and make adjustments to her diet as necessary.

Proposed Strategy 1: MI-Consistent Referrals

Perhaps the most di cult no-show problem to address is the client who no-shows the rst appointment. Although there are a number of reasons that clients may no-show, low motivation has been identi ed as one reason clients might no-show for initial appointments (Peeters & Bayer, 1999). e good news is that incorpo- rating MI into the referral process can increase initial session attendance (seal et al., 2012). ere are multiple ways to make referrals that do not actually occur within the context of a motivational interview more MI-consistent, such as ask- ing permission (e.g., “If it’s okay with you, I’d like to refer you to a dietician to provide additional support and guidance on your weight loss e orts”), empha- sizing control (e.g., “I’m going to go ahead and make a referral to a dietician, but it is really up to you to decide whether that is going to be the right strategy for you”), or o ering choices (e.g., “I think we have three options right now: you can continue to try to lose weight on your own using some of the ideas your friends

74 MoTIvATIoNAl INTeRvIeWINg FoR ClINICAl ChAlleNges

have shared with you, I can go ahead and refer you to a dietician now so you can start working with someone on changing your diet, or I can follow up with you in 3 months and we can revisit the issue then”). each of these strategies intro- duces some element of collaboration and support of autonomy, but on their own, do not make the referral fully MI-consistent.

As outlined in chapter 3, a provider and client will proceed through a series of processes during a motivational interview: engaging, focusing, evoking, and planning. Although the progression may not always be neatly stepwise and linear, each process builds upon the prior processes in important ways. For example, it would be di cult to collaboratively identify a focus for an inter- action with a client who is not engaged in the interaction. As referrals occur during the planning process of a motivational interview, making a referral that is fully MI-consistent relies upon rst engaging the client, collaboratively iden- tifying a focus for the interaction, evoking the client’s own motivations for making a change, and then collaboratively developing a plan for change that may include a referral.

e MI-consistent referral will be of little use to the provider who is on the receiving end of a referral that was made in an MI-inconsistent fashion and results in a client who never makes contact with the provider. us, we present this not as a strategy for addressing no-shows in which the client never shows up for the initial visit, but for reducing the likelihood that the clients to whom you o er referrals will end up as future no-shows.

Example: MI-Consistent/Inconsistent Referrals

e following examples will illustrate MI-consistent and MI-inconsistent referrals to a dietician for Mary, the client introduced in the earlier example.

Client statement: “I keep trying to lose weight, but I never lose more than a few pounds and I always gain it right back.

MI-Inconsistent: “You need to meet with our dietician. She can help you plan a diet you can stick to. I’ll have the nurse call in the referral a er this appointment.”

is is an MI-inconsistent referral because it is not collaborative. e pro- vider tells the client what to do and makes the referral without having any understanding of whether the client is interested in working on weight loss, why she is interested, or the ways in which she prefers to approach weight loss.

somewhat MI-Consistent: “Many of my patients nd meeting with a dieti- cian very helpful when they get stuck. Does a referral to our dietician seem like something that would be helpful for you?”

is referral is somewhat MI-consistent because the provider acknowledges that although a dietician has been helpful for others, it may not be helpful for this particular client. e provider also invites the client to express dis- agreement with the provider’s views on the bene ts of the referral. It is not

less Ready to Change 75

fully MI-consistent, however, because the provider o ers advice without rst seeking to elicit the client’s own ideas about weight loss.

MI-Consistent:
engaging: “ at must be very frustrating [uses re ection to help engage the

client].”

Client Response: “It is.”

Focusing: “I do need to review a few changes in your blood sugar with you before we wrap up, but what are your thoughts about rst spending a few minutes talking about the struggles you’ve had with your weight?” [Asks an open question that invites Mary to help focus the session].

Client Response: “I think that would be very helpful. I know that it is so important for my health and that maybe I could even reverse my diabetes if I lost weight. I really am trying, I just can’t seem to stick to a plan.”

evoking: “Weight loss is hard work [o ers a supportive statement to maintain engagement]. In addition to the role it might play in helping you manage and possibly even reverse your diabetes, I’m wondering what other bene ts you hope you might obtain from losing weight?” [Asks an open question to evoke change talk].

Client Response: “I know I’d feel better about myself if I lost some weight. I’ve never been skinny and I don’t know that I’d want to be, but I’ve also never been this heavy. I think my kids also worry about me now that I’m so heavy and that makes me feel really guilty.”

Planning: “It sounds like there are a lot of reasons you’d like to lose weight. What do you think is a good rst step?” [Use an open-ended question to allow the client to collaborate on the planning]

Client Response: “I know I eat too much, especially when I’m stressed out. Sometimes I’ll order a family meal just for myself.”

Planning continued: “It sounds like you believe making some changes to your diet is an important rst step. One option you may or may not be interested in is for me to refer you to a dietician so she can help you plan a diet that would be a good t for you. What are your thoughts about that?”

is response is MI-consistent, because the referral is made in a collabora- tive fashion and only a er the provider has su cient information about the client’s preferences and motivations to know that a referral to a dietician is a good t for the client. It is also MI-consistent because the provider gives the client the opportunity to refuse the referral, which supports her autonomy.

Proposed Strategy 2: Giving Information

one of the most basic, but at times very important, strategies to address missed appointments is provision of accurate and objective information. Although

76 MoTIvATIoNAl INTeRvIeWINg FoR ClINICAl ChAlleNges

giving information is not a strategy that is central to the practice of MI, when done in an objective and engaging fashion, it is MI-consistent (lane & Rollnick, 2009). Two pieces of information that may be especially important in deterring missed appointments are: (1) the purpose of the appointment, especially as it relates to the client’s goals; and (2) the provider’s appointment policy (e.g., can- cellation policy, penalties for missed appointments, etc.). Clients who do not understand what will happen at the appointment or who are uncertain of the bene t they are likely to receive from the appointment may be less likely to make attending the appointment a priority. is might be particularly true for clients who are referred by other providers, coerced by the legal system, or strongly encouraged by friends or family members to seek the services of a particular provider. Clients who are not made aware of the appointment policy may not understand the implications of missed appointments or the appropriate steps to take when they need to miss an appointment.

Example: MI-Consistent/Inconsistent Giving Information

e following examples will illustrate MI-consistent and MI-inconsistent strategies for giving information to clients who have missed appointments.

Provider statement: “I see it’s been 5 months since our last appointment.”

Client statement: “I couldn’t make it to our last appointment, because my foot was bothering me again, and then the next appointment I could get was a month later.

MI-Inconsistent: “Yeah. Well, it’s a very full clinic, so you need to make com- ing in a priority. If you don’t get your diet under control you run the risk of losing your foot and I know you don’t want that.”

is statement gives the client some information about the appointment policy and the purpose of the appointment, but the information is not pre- sented in an objective fashion and thus is not MI-consistent. e provider blames the client for the missed appointment (accusing her of not making it a priority), and then confronts her about her dietary control (trying to scare her into better attendance).

somewhat MI-Consistent: “ at happens sometimes. is is a very a full clinic.”

is statement is somewhat MI-consistent. e provider o ers informa- tion that is relevant to what the client has said and is objective. however, the provider does not ask permission to o er information and thus misses an opportunity to enhance collaboration and increase the client’s sense of autonomy. Perhaps more importantly, the provider does not empathi- cally address the client’s seeming sense of frustration with having to wait a month for an appointment. us the provider’s response might seem dis- missive to the client.

MI-Consistent: “If it’s okay with you, I’d like to take a moment to address that concern with you. [Awaits a rmative response from client]. is is a pretty

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full clinic, so o en the next available appointment is a few weeks or even a month a er clients call. at can be a challenge because monthly appoint- ments are considered very important for our clients who are diagnosed with type 2 diabetes: dietary management of blood sugar helps reduce risk for dia- betic complications like foot problems. What are your thoughts about this?”

is response is MI-consistent, because the provider o ers the information in an objective fashion. e provider does not seek to chastise or blame the client for missing the session or scare her into coming regularly by pre- senting a worst-case scenario. Instead, the provider presents information that will help the client decide what level of priority she wishes to assign regular attendance of appointments. Moreover, the provider tries to express empathy with the client’s underlying feelings about having di culty get- ting an appointment by using words like “concern” and “challenge.” Finally, the provider elicits the client’s reactions to the information to enhance collaboration.

Proposed Strategy 3: Planning

Planning is another MI-consistent strategy that can be used to address missed appointments, particularly if they occur with regularity. As outlined here and in chapter 3, planning is a collaborative conversation between a provider and a cli- ent about how a client will achieve his or her goals. Planning only occurs a er a client has been engaged, a focus has been identi ed, and a client’s desire, ability, reasons, and need for change have been evoked. For clients who have expressed a commitment to attending appointments but seem to have di culty follow- ing through on this commitment, planning that focuses speci cally on appoint- ment attendance may help them overcome practical or motivational barriers to follow-through.

Example: MI-Consistent/Inconsistent Planning

e following examples will illustrate MI-consistent and MI-inconsistent strategies for planning with clients who have missed appointments.

Provider statement: “I see it’s been 5 months since our last appointment.”

Client statement: “I couldn’t make it to our last appointment because my foot was bothering me again, and then the next appointment I could get was a month later.

MI-Inconsistent: “I think we need a plan to help you attend visits more regu- larly. Do you have a calendar or schedule where you could write down your appointments? If not, maybe you could post your appointment card on your bathroom mirror or refrigerator. You know, somewhere where you’ll see it? I’m also wondering if the reminder calls are coming to the best phone number. Maybe you should pick a better number to make sure you don’t miss the calls?”

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is provider response is MI-inconsistent because it is not a collabora- tive approach to planning. Instead of seeking the client’s input about why attendance is di cult and what the best approach to improving attendance might be, the provider assumes the expert role and begins o ering the cli- ent advice about how best to attend future appointments. is approach is likely to elicit sustain talk and discord as the client is placed in a position to defend not making her appointments or why a strategy might not work.

somewhat MI-Consistent: “Do you want to work together to develop some strategies to help prevent that from happening to you again?”

is statement is somewhat MI-consistent. e provider invites the client to develop a plan to reduce no-shows in a collaborative fashion. however, the provider uses a closed question, and thus invites only a brief response. Additionally, the provider jumps to planning before re ecting or eliciting anything from the client about her desire, ability, reasons, or need to attend more follow-up visits.

MI-Consistent: “It seems like it has been di cult for you to make it in for appointments. I wonder if before we talk about your diet, we could talk about that. [Waits for a rmative response from client]. Given that you always reschedule, I get the sense that you’d like to make it to more follow-ups. If it’s okay with you, maybe we can work together to gure out how we can make that happen.”

is response is MI-consistent because the provider uses re ective listening and asks permission to introduce the change plan. It is also MI-consistent because the provider engages the client in a collaborative process of devel- oping the change plan that begins with a re ection of the client’s apparent desire to change.

Although not required, planning will o en be accompanied by prepara- tion of a written change plan (Miller and Rollnick, 2002). e sample form presented in Table 4.1 illustrates how a provider might develop a written change plan that speci cally addresses “missed appointments.” Although many providers prefer not to use written change plans, feed- back we have received from many clients over the years is that written change plans serve as a valuable reminder of key concepts discussed with a provider.

Proposed Strategy 4: Emphasizing Autonomy

As noted in chapter 2, respecting client autonomy is part of the foundational spirit of MI. Missed appointments are an important reminder to providers that client autonomy is also a practical fact of our work as helping professionals. Providers can make referrals, schedule appointments, and even make reminder calls, but ultimately the client will decide whether he or she shows up at a recommended or required visit. explicitly emphasizing client autonomy is an MI-consistent

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less Ready to Change 79 Table 4.1. sample Change Plan for Missed Appointments

ese are the reasons I want to attend follow-up appointments:

• Regular follow-up visits keep me accountable for my diet.

• I will be more likely to lose weight if I come to follow-up visits.

My goal for follow-up appointment attendance is:

• To attend all follow-up visits on the recommended schedule.

ings that have made it hard for me to attend follow-up visits are:

• I feel embarrassed to tell you about things I have been eating.

• I have trouble motivating myself to leave the house and come to the
appointments.

e actions I will take to overcome these barriers to attending follow-up visits:

• I will remind myself that even if I don’t follow my diet, going to appointments
is important and something I should feel proud about—at least I’m doing something.

• I will schedule appointments on days when I have other errands, so I have to
leave the house anyway.

• I will make a list of all the reasons it is important for me to come to these
appointments and post it on my bathroom mirror.

You and others could help me attend more follow-up visits in these ways:

• You could remind me that it is okay for me to come in even if I haven’t been suc- cessful on my diet.

• My sister could help keep me accountable if I tell her I have been having trouble
going and ask her to remind me.

If the plan is not working:

• I will remind myself that you are not mad at me, and want to work with me to
try to attend appointments.

• I will make another list of why this is so important to me and keep trying.

strategy that may help reduce missed appointments, particularly for clients who feel some level of external coercion to attend appointments.

Example: MI-Consistent/Inconsistent Emphasizing Autonomy

e following examples will illustrate MI-consistent and MI-inconsistent strat- egies for emphasizing autonomy with clients who have missed appointments.

Provider statement: “I see it’s been 5 months since our last appointment.”

Client statement: “I couldn’t make it to our last appointment because my foot was bothering me again, and then the next appointment I could get was a month later.

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commit to or not!”

is provider response is MI-inconsistent because the provider is giving the client a direct order. Also, the tone of voice we intended to imply by the exclamation point demonstrates a lack of empathy and unconditional positive regard, instead conveying the provider’s irritation with the client.

somewhat MI-Consistent “You are the one who has the power to decide whether these monthly appointments are something you want to commit to or not.”

is provider response is somewhat MI-consistent. e provider empha- sizes that the client has control over whether she continues working with the provider or not, which is MI-consistent. however, the provider uses the word “want,” which subtly conveys that she believes the client’s motivation, not foot problems or scheduling di culties, is the root of the patient’s lack of attendance. us the client may feel blamed or confronted by this utter- ance rather than empowered. e provider also fails to express empathy for the client’s frustration or foot pain. is could lead the client to believe that the provider does not really care about her as a person, only whether or not she shows up for appointments.

MI-Consistent: “I know it sometimes takes a major e ort to make it here for appointments, and ultimately it is up to you to decide whether monthly appointments are something you can commit to now.”

is response is MI-consistent because the provider rst supports the di – culty the client sometimes has making it to appointments, and then without sarcasm or judgment reminds the client that ultimately it is up to her to decide whether she would like to attend regular appointments or not. Using this MI-consistent strategy does not guarantee that the client will commit to coming to regular appointments—she might decide that she does not want to meet with the dietician monthly at this time. Although probably not the ideal outcome from the perspective of the dietician, this is not a bad outcome. If Mary is truly not ready to commit to monthly appointments with the dietician, it is better that she and the dietician can talk about this openly. is leaves the door open for Mary to return to the dietician when she is ready.

CLINICAL CHALLENGE 2: NON-ADHERENCE

Description

Many providers are attracted to MI as a way to help them better work with the issue of non-adherence. Consistent with the MI literature, we are choosing to use the term “adherence” versus “compliance” (Zweben & Zucko , 2002). You may remember from chapter 1 that MI has research support for facilitating treatment engagement and adherence (lundhal et al., 2010). Adherence generally refers to

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the extent to which a client follows a provider’s instructions or advice (levensky & o’Donohue, 2006). Non-adherence is an issue o en faced by providers, espe- cially when clients are required to change in some way. Many medical treatments, including taking medications or surgery, require some form of behavior change, such as following the prescription or increased physical activity. People we train frequently express frustration with their clients’ non-adherence to a treatment program because adherence is linked to positive treatment outcomes (Bisono, Manuel, & Forcehimes, 2006). With further exploration, it is o en revealed that this frustration is associated with conceptualizations that non-adhering clients aren’t motivated, are in denial, don’t have enough knowledge or skill, or simply do not care about their health or situation. Clearly, when we conceptualize cli- ents’ non-adherence in this way, it can increase our frustration and also in uence the way we respond. Many times this conceptualization of client non-adherence triggers the “righting re ex” (see chapter 2) and leads us to educate, warn, lec- ture, or even berate clients in an attempt to convince them of the need to adhere to our recommendations. however, those responses tend to be inconsistent with an MI approach to working with non-adherence.

Client non-adherence is expressed in several ways, and from an MI perspec- tive it is an indicator that the provider and client are not on the same page. In fact, levensky and o’Donohue (2006) indicated that factors such as client-provider communication, trust, and mutual conceptualization of the problem contrib- ute to non-adherence. some clients are considered non-adherent because they come to appointments late or simply do not attend appointments (see section on missed appointments in this chapter for further information). is form of non-adherence is common when clients come to treatment at the suggestion of someone else and not by their own choice. us, non-adherence may be due to the clients feeling as though they have no input into the treatment.

example: Shelia is a 20-year-old college student who was told to see a peer health educator by the student health services to learn to implement safer sexual practices. Immediately upon entering the room with the peer health educator, Shelia indicates that the health services worker was overreacting and that she is a normal college student and behaves the same sexually as all of her friends. Nonetheless, she agrees to attend sessions. Since that initial meeting, Shelia sporadically attends sessions and sometimes goes weeks with- out attending. She o en arrives 10 minutes late for meetings and always has a reason for missing meetings or arriving late. When asked directly, Shelia states she is committed to attending the meetings because she was told to do so, but her behavior is inconsistent with this assertion.

sometimes clients do not even engage in a recommended treatment or drop out early. is form of non-adherence may be seen in allied health and behavioral health services, where clients are referred by medical providers for treatments in addition to medical interventions. however, clients may be less con dent in the need for non-medical treatments or question the motives of the referral to

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additional treatments. As psychologists who have worked in medical settings, we o en encountered clients who felt dismissed or invalidated because they had been referred to us to address medically related issues—“the doctor thinks it’s all in my head.” is client mindset may keep clients from engaging in treatment. Additionally, there may be nancial, logistical, or other barriers that may in u- ence clients’ abilities to attend sessions.

example: Karl is a veteran who was referred to a psychologist by his physi- cian assistant to help address his chronic sleep di culties. Before the inter- view begins, Karl indicates that he doesn’t believe seeing a “shrink” will help his sleep and that he just needs some sleep medication. However, it becomes apparent that Karl’s sleep di culties are associated with trauma that he experienced in the military. When this feedback is shared with him and a course of treatment is suggested, he denies any problem with his military ser- vice. Karl never returns to treatment.

Finally, clients may attend all of their scheduled sessions and be on time, but do not carry out the plans discussed for out-of-session activities, such as home- work or taking medications. is form of non-adherence can be ba ing for many providers who assume that when clients readily “walk in the door” that they are ready to do what is necessary to change. however, this is not o en the case when it comes to behavior change, and to be MI-consistent providers need to recognize the role of ambivalence.

example: Jody is a 47-year-old woman who entered psychotherapy for her social anxiety. She is also seeing a psychiatrist for medication management. She has expressed the goal of wanting to reduce her anxiety and to be able to attend more social events without worry. Jody reports that she does not take her medication regularly as she worries about developing an addic- tion, though her medication is not addicting. She indicates that she wants to do what it takes to become less anxious and more social; thus she agrees to treatment involving exposure and skill building. However, she has a pattern in treatment of not completing her self-monitoring, exposures, or skill prac- tice outside of session (for more information about speci cally addressing non-adherence related to anxiety, see also chapter 6).

Regardless of how non-adherence is displayed, from an MI perspective it is an indication that the provider and client are not on the same page in relation to the change or how to go about changing (Bisono et al., 2006).

Proposed Strategy 1: Evocative Questions

Using evocative questions in relation to non-adherence can help avoid the right- ing re ex. evocative questions can also help the provider adopt an approach that is grounded in genuinely trying to understand what concerns the client may have

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about changing or not, what their personal motivations for changing may be versus what a referral source may want, and what potential solutions seem rea- sonable. Remember the U from RUle in chapter 2—understanding the client’s motivations. It is the client’s own motivations that are more likely to predict their engagement in and adherence to treatment. us it is very important to elicit these from clients, especially when trying to engage them into treatment.

Example: MI-Consistent/Inconsistent Evoking

e following examples will illustrate MI-consistent and MI-inconsistent evoking for clients with non-adherence issues.

Client statement: “I think all I need is medicine for this problem. No o ense but I don’t come here as o en because I don’t think talking about my sleep will help.”

MI-Inconsistent: “Do you really think that medication is the only thing that will help you sleep?”

is question is MI-inconsistent for two reasons. is question is a closed question and unlikely to foster open discussion about the topic from the cli- ent. Additionally, the “do you really” part of the question is likely to engen- der discord as it can be perceived as judgmental and confrontational.

somewhat MI-Inconsistent: “Why don’t you think therapy will be helpful?”

is question is somewhat MI-consistent. It is an open question and thus invites the client to share. however, the “Why don’t you . . . ” phrasing of the question subtly implies that the client should think therapy will be helpful and thus may elicit discord as the client feels a need to defend his position to the provider. e phrasing of the question is also likely to evoke sustain talk (reasons not to get this particular treatment) rather than evoking the client’s perspectives on what would be helpful.

MI-Consistent: “You want to solve this sleep problem, and for you medication seems like the best option. If it is okay with you I’d like to hear your thoughts about why you think your physician referred you to me.”

is statement is MI-consistent for a few reasons. First, with the re ection, the provider communicates listening to the client and an understanding of the experience. Rather than jumping into education, the provider asks an evocative question that invites the client to comment on his/her under- standing as to why the physician made the referral. is approach helps the provider avoid the righting re ex (e.g., “behavior change can help with sleep too”) and fosters client engagement in the discussion.

Proposed Strategy 2: Scaling Questions

A strategy related to the use of evocative questions is to ask scaling questions, sometimes called importance and con dence rulers. In MI, these types of ques- tions help the provider gauge whether clients’ reluctance to change may be due to

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their perceived importance of the change or their perceived con dence in their abilities to change (Miller & Rollnick, 2013). For instance, the provider can ask “On a scale of 0 (not at all important) to 10 (extremely important), how important is it to you to make this change?” e use of scaling questions is not unique, but what is unique is the intentional follow-up to scaling/ruler questions. In MI, fol- lowing up to ask what makes the number on the scale higher versus lower is intended to elicit reasons why change may be important or why clients may have some con dence in their ability to change.

Example: MI-Consistent/Inconsistent Scaling Questions

e following examples will illustrate MI-consistent and MI-inconsistent scaling questions for clients with non-adherence issues.

Client statement: “I think all I need is medicine for this problem. No o ense but I don’t come here as o en because I don’t think talking about my sleep will help.”

MI-Inconsistent: “On a scale from 0 (not at all important) to 10 (very impor- tant) how important is it for you to attend these sessions?”

is is de nitely a scaling question but is MI-inconsistent for two reasons. First, the use of a question like this, especially in the context of missed appointments, could lead the client to become defensive and increase dis- cord. second, the scaling question is not really about change (i.e., improv- ing sleep, reducing trauma symptoms); it is more about the importance of the sessions. us, there is a missed opportunity to explore the client’s hesi- tancy to change or importance of change.

somewhat MI-Consistent: “On a scale from 0 (not at all) to 10 (very much), how important do you think this treatment is relative to the medication?”

is scaling question is somewhat MI-consistent. e provider uses a scal- ing question to better understand how the client feels about psychotherapy. e use of the question also likely conveys to the client that his concerns about treatment are being taken seriously by the provider. however, the phrasing of this question is such that the discussion that follows the ques- tion is unlikely to help the client move toward the improvements he desires in sleep. us the utterance is empathic and collaborative, but may miss an opportunity to guide the client toward positive change.

MI-Consistent: “You have a lot going on in your life and found the time to make it here today to address your concerns. If I might ask, on a scale from 0 (not at all important) to 10 (the most important thing for you), where does making changes to your sleep fall?”

Client response: “About a 4.”

MI-Consistent: “So it is mid-range on the sale. What makes the importance a 4 and not a 2?”

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ese provider utterances are MI-consistent for several reasons. First, the provider begins with an a rmation by reframing the client showing up as a positive given all of the things going on in her/his life. Next, the provider focuses on the change versus the non-adherence behaviors. By using a scal- ing question to focus on the importance of the behavior, the provider gets a better picture where the change ts in relation to other things in the cli- ent’s life. Finally, the follow-up question is likely to guide the client to dis- cuss why there is some importance to changing the behavior, which is more likely to build motivation.

Proposed Strategy 3: Looking Forward

sometimes clients are less aware of how their non-adherence to treatment might have an e ect on their future. As humans we tend to have narrow perspectives about our future as it relates to changing or not (Wagner & Ingersol, 2013). For instance, in a medical setting a client may “feel ne” but be pre-hypertensive. Because the client feels ne he may not see the need to address his diet or exercise to lower his blood pressure. however, unless addressed, his blood pressure is likely to get worse. us, one MI-consistent strategy that can facili- tate adherence is helping the client connect how their current situation and non-adherence might a ect their life in the future. In MI, this strategy is called looking forward.

Example: MI-Consistent/Inconsistent Looking Forward

e following examples will illustrate MI-consistent and MI-inconsistent looking forward for clients with non-adherence issues.

Client statement: “I think all I need is medicine for this problem. No o ense but I don’t come here as o en because I don’t think talking about my sleep will help.”

MI-Inconsistent: “Yes, medication can help. However, if we look down the road and you don’t change thoughts and behaviors related to your sleep, your sleep is likely to get worse, which will then increase your vulnerability to many other problems!”

e provider o ers accurate information about the progression of sleep dif- culties and the vulnerability for other issues if the sleep doesn’t change. however, the statement is MI-inconsistent as the provider is assuming the expert role and providing the information without asking permission. Additionally, rather than eliciting from the client about the future, the provider simply connects the dots for the client. is approach fosters less engagement and likely to elicit sustain talk from the client.

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somewhat MI-Consistent: “I have a di erent perspective. Would it be okay if I shared it with you? [Waits for a rmative response]. I have been doing this for years, and generally people who rely on medication and don’t address the other problems contributing to sleep di culties continue to have problems with sleep.”

is response is somewhat MI-consistent. e provider asks permission before o ering his professional opinion. however, the provider uses this information to try to instill motivation for treatment rather than eliciting the client’s own concerns about what might happen if he does not pursue any treatment other than medication for his sleep di culties.

MI-Consistent: “You wonder why all of these changes are necessary when medication should help you with your sleep. I wonder if we can look 5 years down the road for a minute. Let’s say you decided not to make any of these changes in relation to your sleep. What might your health look like? [client responds] How might your health be di erent if you decided to make some changes in your sleep behaviors?”

is provider statement has several aspects that make it MI-consistent. e provider re ects the client’s concerns about changing. e provider asks permission to look into the future and follows with two eliciting questions. is approach is more engaging and collaborative. e provider makes no assumption that the client will change and avoids the expert trap.

Proposed Strategy 4: Revising the Change Plan and Discussing Options

o en individuals are less willing to adhere to treatment when they perceive that they have few options in relation to the change; thus, they assert their indepen- dence by not adhering to the treatment plan. A concept from social psychology will help to explain this. According to Brehm and Brehm (1981), individuals have a natural tendency to react (or assert their independence) when they feel their freedom is being taken away. In other words, as humans, it is natural for us to argue against being told what to do. e ultimate way clients demonstrate this is by not adhering to the change plan. In training providers to become more MI-consistent when developing change plans, we o en nd that providers are far less MI-consistent in this process than they believe themselves to be. Many pro- viders prescribe a change plan followed by a question, such as, “Does this sound okay to you?” some providers mistakenly assume that this question makes the entire planning process MI-consistent. is strategy seems to be based on the belief that once a client indicates readiness to change it is the provider’s job (as an expert) to tell him how. one way to avoid a client pushing back or not adhering to treatment is to engage the client in the planning process. For example, a provider

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may discuss various change options and elicit which, if any, may seem to be most appealing to the client. given that MI-consistent planning was discussed earlier in this chapter (see missed appointments section), this discussion will focus on discussing options as part of the planning process.

Example: MI-Consistent/Inconsistent Discussing Options

e following examples will illustrate MI-consistent and MI-inconsistent discussion of options for clients with non-adherence issues.

Client statement: “I think all I need is medicine for this problem. No o ense but I don’t come here as o en because I don’t think talking about my sleep will help.”

MI-Inconsistent: “For many people, medication can help but only so far. e combination of medication and cognitive behavioral therapy is generally most e ective for people with your symptoms!”

While accurate, the statement is MI-inconsistent. e statement appears to adopt an expert role commenting on the e ectiveness of medication and cognitive behavioral interventions for sleep. similarly, the provider o ers information in a fashion that is not fully MI-consistent because he/she did not ask permission or announce that he/she was going to provide informa- tion. e statement is challenging to the client, prematurely focuses on a problem, and prescribes a solution. All of these aspects of the statement are likely to elicit sustain talk from the client and engender discord between the client and provider.

somewhat MI-Consistent: “I think we have several options here. You could continue to see me regularly and see how it goes. You could try some, but not all, of the strategies I recommend. Or you could discontinue this treatment and come back again later, if you change your mind. What sounds best to you?”

is response is somewhat MI-consistent. e provider gives the client options and invites the client to choose which seems best. however, the pro- vider does not ask permission before o ering the options and does not leave open the possibility that the client may have di erent ideas about what the best solution might be. us although the provider seeks to be somewhat collaborative in discussing options and updating the change plan, the e ort is lukewarm.

MI-Consistent: “For you medication seems like a viable option, and you’re not too sure whether also working with me to address sleep behaviors is going to give you additional bene t. At the same time, your psychiatrist has asked for you to see me which suggests she thinks working with me might be ben- e cial. If it is all right with you, I’d like for us to discuss some other options that I have seen clients in similar situations use to help with their sleep. I also recognize, that these options may or may not t for you, and you may have some additional ideas.”

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is provider statement has several aspects that make it MI-consistent. Beginning the statement with a re ection communicates that the provider is listening and empathizing with what the client is saying. e provider asks permission to engage in a discussion about options for change. e provider discusses options in the context of what others in a similar situa- tion have done to help with their sleep versus prescribing options based on professional opinion or research. Finally, and discussed later, the provider emphasizes the client’s personal control to choose what she/he deems best.

Proposed Strategy 5: Emphasizing Personal Control

Related to the importance of discussing options in relation to non-adherence is the need to emphasize clients’ personal control to choose what they think is best for them. Miller and Rollnick (2013) highlight the fact that we really can’t make clients do something they don’t want to do, and clients show us by not adhering to their treatment plans. is idea also relates to reactance theory. one way to address this issue is to remind clients that ultimately the choice for change is theirs and no one else’s. is is true even when they are mandated to change.

Example: MI-Consistent/Inconsistent Emphasizing Personal Control

e following examples will illustrate MI-consistent and MI-inconsistent emphasizing of personal control for clients with non-adherence issues.

Client statement: “I think all I need is medicine for this problem. No o ense, but I don’t come here as o en because I don’t think talking about my sleep will help.”

MI-Inconsistent: “It is your choice what you do here, but I don’t think your psychiatrist is going to be very happy with you if you don’t follow his advice about adding psychological treatment.”

e provider does emphasize the client’s personal control; however, the statement also includes an implied warning that the provider has to report the non-compliance with treatment back to the psychiatrist, which may lead to negative consequences for the client. In essence, by adding the warn- ing the provider is communicating that the client does not have any control in this situation. is statement may also enhance the client’s sustain talk or attempt to convince the provider that a problem doesn’t exist. It also could engender discord between the client and provider as the client may feel threatened and that the provider is siding with the psychiatrist.

somewhat MI-Consistent: “Well it’s really up to you. No one can make you come to these appointments if you don’t want to.”

is statement is somewhat MI-consistent. e provider emphasizes the cli- ent’s personal control, which is MI-consistent. however, the provider does so without expressing empathy or encouraging the client to further explore

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whether treatment termination is the best option for him, all things consid- ered. is might leave the client with a sense that the provider really does not care whether the client’s sleep improves or not, and is only interested in making sure that the treatment slot is lled with someone who comes regularly.

MI-Consistent: “You are only here because your psychiatrist referred you here, but psychological treatments for sleep don’t make a lot of sense to you. De nitely any changes you decide to make or not make, including seeing me for treatment, are up to you and I can’t force you to do anything. At the same time I wonder about your thoughts as to why your psychiatrist thought that this might be bene cial for you.”

is is an MI-consistent response for several reasons. e provider avoids taking sides by empathizing with the client’s frustration about being referred by the psychiatrist. Next, the provider emphasizes the client’s per- sonal control to choose to make or not make any changes. Finally, the pro- vider invites the client to comment on what his/her ideas about why the psychiatrist may have referred him for additional treatment. A statement like this encompasses the spirit of MI, communicates acceptance and col- laboration, and uses evocation. is statement is more likely to engage the client, reduce sustain talk and discord, and help the client to be more open to later suggestions.

CLINICAL CHALLENGE 3: CLIENT INVOLVED IN THE LEGAL SYSTEM

Description

Client involvement with the legal system can lead to particularly di cult client-provider interactions. legal involvement comes in many di erent forms, each of which can introduce unique clinical challenges. Clients who are court-ordered, court-referred, or encouraged to seek services by an attorney prior to their court date to make a favorable impression upon the judge may enter treatment pre-contemplative about behavior change ( ombs & osborn, 2013). at is, these clients may not perceive any reason to make changes, and may believe that the only bene t they will get from meeting with a provider is to improve their legal standing. Clients of this type are most o en found in the pro- bation/parole system, substance abuse treatment, domestic violence treatment, and similar settings.

example: A er a substantiated allegation of child abuse, Jane was sentenced to probation and referred to an intensive parent training and anger manage- ment program. Custody of Jane’s children has been temporarily granted to her ex-husband’s parents and she has been informed that her children will

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not be returned to her custody unless she successfully completes the 12-week program and satis es other conditions of her probation. Jane has also been informed that she may face additional legal penalties if she does not com- plete the 12-week program. Jane believes that stern physical discipline is an essential part of raising responsible, well-behaved children and resents her “touchy-feely, liberal” neighbor, who she is certain called in a report to the child welfare department. During her intake interview for the program, Jane is very quiet and reserved, and seems focused primarily on nding out what the program will report back to the court and probation department and what exactly the program requires to make a favorable report about her.

Interactions with legally involved clients who present for treatment or services that are not required or encouraged by the legal system may still present serious clinical challenges. Clients who are involved in pending litigation or who per- ceive that future legal involvement is possible or likely (whether or not this is in fact true), may feel compelled to present themselves in a particular light in order to achieve legal goals, such as a favorable legal settlement, or avoid anticipated negative consequences of honest disclosure, such as a harsher sentence or loss of custody of a child.

example: Bob is in the midst of what could best be described as a “messy divorce” and is seeking counseling to help him cope with the stress and address symptoms of anxiety and depression that have emerged since he and his wife separated. Bob would also like to use therapy as an opportunity to work on his di culty controlling his temper, as he believes that has contributed to prob- lems in his marriage. Bob is reluctant to disclose this problem to the therapist, however, because he is concerned that his therapy record will be subpoenaed during the divorce proceedings. Bob is afraid that admitting he has an anger problem may negatively impact him in the divorce proceedings.

Proposed Strategy 1: Giving Information

one factor that can needlessly increase discord and decrease client candor dur- ing MI sessions with clients who are involved in the legal system is uncertainty on the part of the client about whether and what types of allegiances or obliga- tions the provider may have to the legal system. It is important to note that even clients who have no involvement with the legal system may have such concerns. For example, an individual who is being treated in the emergency room subse- quent to a motor vehicle accident may be defensive or anxious when asked about her use of drugs or alcohol prior to the accident, if she believes that information will be or could be reported to police. us a very simple, MI-consistent strategy we have found very useful in addressing this challenge is giving information.

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At the outset of an interaction with clients who have legal involvement of any sort (or who may perceive legal involvement), it is important to provide clear, unambiguous information about the provider’s role, if any, in the legal system. As described further in chapter 3, to be MI-consistent, it is also important that any information given to the client is delivered in an objective manner. Although not technically required (Moyers, Martin, Manuel, & ernst, 2010), it is more MI-consistent and generally bene cial if providers ask permission before giv- ing information. In the case of probation, parole, or similar contexts, provid- ers should fully disclose the dual roles they have with clients. In one role the provider represents the criminal justice system, reporting the client’s progress on meeting the conditions of his or her probation or parole, including viola- tions. In the other role, the provider acts as an advocate for the client and tries to help him or her achieve important goals (Walters, Clark, gingerich, & Meltzer, 2007). As Walters and colleagues suggest, this dual relationship may decrease the willingness of some clients to disclose certain information for fear of sanc- tions. however, the willingness of the provider to proactively provide full infor- mation about the dual relationship is highly consistent with the foundational spirit of MI, which emphasizes collaboration and support of client autonomy (see chapter 2). Moreover, in our experience, provision of such information may reduce client willingness to disclose select details about their past or current behavior, but it is likely to enhance client disclosures overall by fostering the cli- ent’s ability to trust the provider.

In the case of a provider outside the legal system, who is simply providing a service that may be of interest to the legal system (i.e., a community-based alco- hol treatment provider working with an individual convicted of driving under the in uence of alcohol or another substance [DUI] who was diverted to treat- ment), the client should be made aware that the provider is not part of the legal system. e provider should also make the client aware of whether the legal sys- tem is likely to require a release of information and what types of information (e.g., attendance, completion, progress, diagnoses, etc.) in order to consider the client’s treatment involvement in determining the client’s legal disposition. e ethical imperative for disclosure of a lack of relationship between the provider and the legal system is not always as clear cut as the imperative for disclosure of the presence of such relationships. however, provision of information about the absence of a connection between the provider and the legal system may help reduce discord or increase client candor in situations where the client might believe such a relationship exists.

Example: MI-Consistent/Inconsistent Giving Information

e following examples will illustrate MI-consistent and MI-inconsistent strategies for giving information to clients who have legal involvement.

Client statement: “I haven’t smoked marijuana in over a month. I don’t know how the drug screen came out positive.”

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MI-Inconsistent: “Marijuana use is a clear probation violation. You need to take this treatment seriously and stop lying to us about your marijuana use. I am going to report this to your probation o cer and I hope he revokes you!”

is statement gives the client information about the relationship between the provider and the legal system, but it is MI-inconsistent because it does so in a non-objective fashion. With this response, the provider obviously discloses this information to the client to establish his own power over the client (non-collaborative) and confront the client about what the provider believes is a lack of candor.

somewhat MI-Consistent: “Before we continue, I feel I must remind you that I am required to report this to your probation o cer.

is statement is somewhat MI-consistent. e provider o ers the informa- tion in an objective fashion. e phrasing “I feel I must” expresses that the provider values the client’s right to have full information about the pro- bation process. us, in a subtle way, this phrasing supports the client’s autonomy. however, the provider does not express empathy for the client’s current situation or support the client’s autonomy in an overt way.

MI-Consistent: “I imagine this unexpected result is upsetting and I would like to discuss how this might have happened. Before we discuss that, I would like to review what this means and doesn’t mean in terms of your legal status. Would that be okay? [Waits for a rmative response]. In addition to provid- ing reports on your treatment attendance, your probation o cer also requires that we provide reports on your progress in treatment, including outcome of urine drug screens.”

is response is MI-consistent because the provider o ers the information in an objective fashion. e provider also asks permission to give the infor- mation, which supports client autonomy and enhances a sense of collabora- tion. e provider also re ects the client’s inferred emotional reaction to a positive drug screen, which demonstrates empathy.

Proposed Strategy 2: Emphasizing Autonomy

As noted in chapter 2, a key element of the “acceptance” component of the foun- dational spirit of MI is respecting client autonomy. Regardless of what a provider wants or hopes a client will do, the client is ultimately the one who determines what he or she actually will do. Clients who believe change is possible and have a sense of agency are more likely to be successful in making positive changes in their lives (Bandura, 2004). Many clients who are involved with the legal system actually have lost control over one or more aspects of their lives. Nonetheless, it is very important for providers to recognize and respect that even clients who are incarcerated and have lost their physical freedom retain autonomy over other aspects of their lives (Farbing & Johnson, 2008). No matter what a client’s legal

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status, he or she generally retains the autonomy to share or not share his/her thoughts and feelings with a provider, to discount or take seriously a provider’s ideas or suggestions.

Nonetheless, loss of autonomy or concern about loss of autonomy can make it di cult for clients to actively engage in the change process. Clients may view themselves as completely powerless and assume a passive role in encounters with providers. Although this might make clients easier to manage and thus be viewed as desirable in certain settings, it may ultimately undermine e orts to promote positive changes in the clients’ lives (Bandura, 2004). Clients who do not col- laboratively participate in the change process may have insu cient motivation to carry out change, or may seek to make changes that are not a good t for their unique experiences, strengths, and preferences. For example, a client who is a passive participant in discussions of employment may be assigned to employ- ment that is of little interest to the client and does not make maximum use of his or her unique skills and experience. loss of autonomy or concern about loss of autonomy in one area of a client’s life may also give rise to unsuccessful and counterproductive e orts by the client to assert their autonomy in other areas of their life (Ryan & Deci, 2000). For example, a client who feels powerless because of his or her involvement with the legal system may react negatively to other aspects of life that are less de ned or constrained.

us, it may be very important for providers who wish to help clients with legal involvement make positive changes in their lives to be aware of the impact of a client’s loss of autonomy and make attempts to restore a cli- ent’s sense of autonomy. Although emphasizing a client’s personal autonomy is an MI-consistent strategy that may be applied during any MI encounter, it is perhaps most powerful with clients who have legal involvement. Using the MI-consistent strategy of emphasizing autonomy involves (as you might guess) supporting a client’s autonomy by emphasizing those aspects of a client’s life that are within a client’s control and actively working to help the client exercise that control.

Example: MI-Consistent/Inconsistent Emphasizing Autonomy

e following examples will illustrate MI-consistent and MI-inconsistent strategies for emphasizing autonomy for clients who have legal involvement.

Client statement: “I miss one check-in and you are talking about revoking my probation and sending me back to prison?”

MI-Inconsistent: “You made a bad choice, and now you’re going to have consequences.”

Although this statement seems super cially like a support of the client’s autonomy because it mentions “choice,” it is MI-inconsistent. e provider labels the client’s choice as “bad” and actually mentions choice as a way of de-emphasizing the client’s autonomy by linking it to consequences the cli- ent does not desire and cannot control at this point.

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somewhat MI-Consistent: “If I could have made sure that you attended the check-in, I would have. But I don’t have that power. You are the one who has that power.”

is statement is somewhat MI-consistent. e provider emphasizes the cli- ent’s autonomy by clearly stating that the client is the one who has the power to decide whether to attend check-in meetings. e provider also expresses compassion by stating, “If I could have made sure that you attended the check-in, I would have.” however, by focusing primarily on what has already happened the provider is less likely to move the client toward posi- tive change from that point forward. Moreover, given that the client did not like the consequences of the missed check-in, this emphasis of autonomy could be interpreted by the client as an attempt to blame the client for miss- ing the appointment.

MI-Consistent: “ e conditions of your probation are set by the court, so my hands are tied as far as what the consequences will be. I know this is disap- pointing for you because you’d been doing well for so long. As you know from experience, your behavior from this point forward can have a big in uence on what happens next, so now it is really in your hands to decide whether it’s worth it to do things that will incline the court to be lenient or not.”

is response is MI-consistent because the provider emphasizes the auton- omy the client does have to try to do things that will impress the court and may result in leniency. e provider also o ers information about conse- quences in an objective fashion and re ects the client’s inferred emotional reaction to the possibility of being sent back to prison, which demonstrates empathy.

Proposed Strategy 3: Initiating Discord

Another useful, MI-consistent strategy for working with clients with legal involvement described by stasiewicz, herman, Nochajski, and Dermen (2006) is initiating discord. is strategy addresses a problem commonly encountered in clients with legal involvement: a strong sense of discord (formerly termed resis- tance) at the outset of an interaction with a provider (before the provider has even initiated a conversation with the client). is sense of discord may have nothing to do with the provider per se, but rather the client’s sense that the pro- vider is part of a system that has wronged or harmed the client in some way. e di culty a provider may face in addressing this discord is that the client may not feel comfortable expressing their anger or resentment at the outset of the session. A client may in fact deny that anything is bothering him or her if asked directly by the provider. however, until the client has an opportunity to express the thoughts and feelings driving the discord in their relationship with the pro- vider, it may be di cult, if not impossible, for the client and provider to move forward in a meaningful way.

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Consistent with prior terminology used to describe discord (Miller & Rollnick, 2002), stasiewicz and colleagues (2006) termed the strategy they developed to address this type of discord “initiating rolling with resistance.” As the name implies, what this strategy entails is proactively creating an opportunity for cli- ents to express their anger, resentment, etc. early on in their contact with the provider. is allows the client and provider to work through it and more quickly focus on whether and what changes the client would like to make. In their work with DWI (driving while intoxicated) o enders, stasiewicz and colleagues described initiating a session by empathically o ering as possible topics for dis- cussion several of the most common discordant statements they encountered when working with DWI clients. Items on this list might include the substantial monetary costs associated with a DWI conviction (e.g., attorney fees, treatment costs, impound fees, lost wages) or a belief that the legal system is harsh on DWI o enders relative to other impaired drivers (e.g., those who text and drive). Not only does this strategy create an opportunity for clients to get their negative feel- ings “o their chest” early in the interaction, it is also a way to express empathy; it gives clients a sense that the provider has some understanding of the experience of receiving a DWI.

e decision to use this strategy should be based upon a provider’s experience in a particular context as well as indications from the client that discord is pres- ent (e.g., a feeling of tension in the room; a hostile voice tone or sarcastic com- ments from the client; quiet, passive responding). Providers who work in settings where clients almost invariably express anger, frustration, resentment, or similar reactions in their early interactions with providers might nd it very useful to develop a list of the most commonly voiced concerns and initiate discord at the outset of initial encounters. is may include settings where legal involvement is not the source of discord. For example, providers in clinics or agencies with long wait times, older facilities, crowded waiting rooms, inconvenient hours, or other factors likely to arouse feelings of frustration or resentment in many clients might nd this as a useful strategy.

Example: MI-Consistent/Inconsistent Initiating Discord

e following examples will illustrate MI-consistent and MI-inconsistent strategies for initiating discord:

Client statement: “Well I’m here. What’s next?

MI-Inconsistent: “Listen, you and I are going to be working together for the next 12 weeks, and this is going to go a lot more smoothly if you lose the attitude.”

is statement is likely to increase discord between the client and pro- vider in a very MI-inconsistent fashion. Rather than proactively creating an empathic, supportive opportunity for the client to discuss negative thoughts and feelings he or she might have about working with the pro- vider, the provider seeks to proactively shut this discussion down by label- ing the client’s thoughts and feelings as a “bad attitude” and issuing what

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might be interpreted as a veiled threat about what might happen if the client expresses negative thoughts or feelings. is is an example of not resisting the righting re ex (see chapter 2).

somewhat MI-Consistent: “Well, during today’s visit we are going to review the circumstances of your DWI arrest and discuss the goals of this program. Does that sound okay to you?”

is statement is somewhat MI-consistent. is statement is somewhat col- laborative in that in response to the client’s question, “What’s next?” the provider presents the session plan and then o ers the client an opportu- nity to either agree or disagree with the plan. however, the provider is not emphatically attuned to the client’s obvious sense of frustration and does not create an opportunity for the client to express that frustration openly. Instead the provider seeks to move ahead with the session as planned in spite of the client’s obvious reluctance.

MI-Consistent: “ ere a few things we need to get done today, but before we dive into that, I’d like to check in with you. A lot of times people who are referred to this treatment have a lot on their minds. Some are pretty upset about what seems like bias in the legal system against them, others feel betrayed by a friend or neighbor who called the police, others think the amount of time at work they lose and the fees they have to spend to attend this group are a little ridiculous, and still others feel very anxious about what this means and what will happen to them because they’ve never been in trouble before. What, if any, of these thoughts or concerns do you have?”

is response is MI-consistent, because the provider does resist the “right- ing re ex” and instead empathically notes from the client’s words and tone that she may not be pleased with meeting with the provider. en, in a sup- portive, empathic fashion, the provider o ers information (a list of potential sources of discord) and an open question that invites the client to express his feelings or concerns.

CHAPTER SUMMARY

No-shows and non-adherence are perhaps among the most ubiquitous clinical challenges faced by providers across disciplines and settings. ere are a broad range of MI-consistent strategies that may help providers reduce no-shows and non-adherence by helping clients increase their readiness to change. Clients who are involved with the legal system or otherwise coerced into a helping relation- ship are also o en less ready to change, and MI-consistent strategies can be valu- able in that context as well. e ectively working with clients who are less ready to change can be facilitated by viewing readiness to change as a process of di erent stages (e.g., “he hasn’t decided for sure whether he’s ready to change”) through which a client may progress, rather than a static characteristic of a particular

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Table 4.2. summary of Motivational Interviewing strategies for Clinical Challenges with less Ready Clients

Clinical Challenge

Suggested MI Strategies

No-shows:

Frequently rescheduling appointments (sometimes at
the last minute)
or not attending regularly scheduled appointments.

MI-consistent referrals: Making referrals in a collaborative fashion and only a er having su cient information about the client’s preferences and motivations to know that a referral is a good t.

giving information: Providing information in an engaging and objective fashion about the nature of the referral and appointment policies.

Planning: engaging the client in a collaborative conversation about how client will achieve his or her goals.

emphasizing autonomy: explicitly communicating that ultimately it is the client’s decision whether he or she attends a recommended or required visit

Non-adherence:

Arriving to appointments late, no-showing, or not following a treatment plan.

evocative questions: Using questions aimed at genuinely understanding the client’s concerns, motivations, and potential approaches to change.

scaling questions: Using a 0–10 scale to elicit how important and con dent a client feels in relation to change.

looking forward: guiding client to look forward in their life and relate change or no change to potential outcomes in the future.

Revising the change plan: stepping back, reviewing, and renegotiating the plan for change focusing on the discussion of multiple versus a single change option.

emphasizing personal control: explicitly and genuinely highlighting client’s right to choose to do what they think is best for them.

legal involvements:

seeking services because of a court mandate, referral, or suggestion from an attorney.

giving information: With permission, provide objective, clear, and explicit information about your role in regard to the legal system, and con dentiality and its limits.

emphasizing autonomy: emphasizing the aspects of the client’s if that are within his or her control when he or she perceives loss of control.

Initiating discord: Proactively creating an opportunity for client to express anger, resentment, or other concerns about the referral.

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client (e.g., “he’s just stubborn”). Doing so can enhance your understanding of client change (or lack thereof) and help you tailor your interventions or the deliv- ery of your interventions to the client’s level of readiness. e important thing to recognize is that clients are less ready for a variety of reasons, and utilizing some of the MI-consistent strategies outlined in this chapter can help you meet clients where they are in their change process and help them to become more ready to change. Table 4.2 summarizes the clinical challenges and suggested MI strategies.

5

Loss of Momentum

People changing o en encounter faster and slower progress toward the change goals, increases and decreases in momentum, setbacks, brief returns to prob- lem behaviors, and even complete return to problem behavior. As outlined more fully in our discussion of Prochaska and Diclemente’s (1983) stages of change in chapters 2 and 4, clients cycle through these stages of readiness to change. us, simply because an individual enters an action or even a maintenance stage does not ensure they will not return to a previous stage of readiness to change. Although not a speci c stage in the readiness to change model, recycling and relapse o en accompany any discussion of the model (Connors, DiClemente, velasquez, & Donovan, 2013).

Quick Reference Relapse

Relapse and recycling: A part of change in which clients may return to previous stages of change (e.g., contemplation) and also reengage in problem behaviors.

Diverse reasons exist for waxes and wanes in client progress. ese reasons can range from changes in importance and con dence, to external barriers like decreases in family support, to entering the change process with unreal- istic expectations. some of these reasons are more manageable for clients and some are less controllable. Whether controllable or not, it is important to rec- ognize shi s in momentum toward a change goal and to further recognize that although a client has been actively changing, loss of momentum is a signal that something has changed that requires parallel change from the MI-consistent provider. generally this change will be a shi from a more directive approach to an MI-consistent guiding style. By viewing shi s in momentum as an opportu- nity to re-engage or recycle through the readiness to change process and adopt- ing an MI-consistent style, a provider can help clients regain the momentum toward change. In fact, the ability to integrate an MI-consistent style when cli- ents lose momentum during the active change process seems to be one of the important bene ts of this approach.

  

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CLINICAL CHALLENGE 1: SLOW PROGRESS

Description

Individuals we have trained frequently express concern about clients who appear to be motivated to change and yet progress slowly in their change e orts. is experience can certainly be confusing and leave providers wondering exactly why their clients are not progressing faster given their expressed desire or need and perhaps even intention to change. You may remember from chapter 2 that change talk, in particular statements about intention, has been identi ed as a pre- dictor of positive change outcomes (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003). In our experience, providers (including us at times) tend to assume that a er clients have expressed an intention to change, we have permission to adopt an active expert role and advise clients what they need to do to change. is is why clients come to see us, right? is assumption o en leads us to develop a plan of action or intervention for the client and then present it to the client. In doing this; however, we fail to honor our clients’ autonomy and elicit their exper- tise to help us determine the best plan of action. We then experience concern, frustration, and even disillusionment with our clients’ slow progress as we place all of the responsibility for their progress, or lack thereof, on them.

An example from our experience might help illustrate this point. I (MM) reg- ularly supervise advanced doctoral students providing psychological services. Many times I have observed students meeting with clients for two sessions to “understand” the clients’ concerns and treatment goals. A er the second session these students sit in the clinic work space and write a treatment plan to present to the client at the third session. several sessions later, I’ve had these students approach me with frustration that the client is not making progress on the treat- ment plan. I tend to respond in these situations with a simple question, “how much of the plan is theirs and how much of it is yours?” e point in this story and in my questioning of my supervisees is to emphasize that, from an MI per- spective, we need to be collaborative and evocative in developing a change plan.

Conceptualizing slow progress as evidence of a need to reassess motivation and reevaluate the change plan may help a provider to adopt a more MI-consistent style in these situations. Miller and Rollnick (2013) and others (e.g., Westra, 2012) remind us of the need to pay attention to shi s in motivation and even the reemergence of ambivalence as clients progress through treatment. ere can be various reasons why progress is slow or slows down ranging from development of the wrong plan, to unexpected di culties with various aspects of the change plan, to life events and barriers that may take precedence over changing.

example: Joel is a 40-year-old man who is seeking career counseling due to recently being laid o from his job. He worked as an accountant for a local bank and is a certi ed public accountant. In meeting with his career coun- selor he was given a list of jobs for which the counselor deemed he was quali- ed and told to apply for each job and return in a week. Upon returning Joel

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informed the counselor that he applied for only one of the jobs as the others didn’t seem to meet his needs or interests in a career. At this information the career counselor asked Joel if he wanted a job. Joel responded to this question with a vehement declaration, “It’s my top priority!” e counselor responded by adding three more jobs to the list that she thought were appro- priate and sent Joel on his way to return in 2 weeks. Upon returning Joel reported applying for one of the new jobs but no others stating that they didn’t seem to meet his needs and interests. Hearing this information his counselor became visibly frustrated and again asked if Joel wanted a job.

Joel’s experience is a common one when there is a schism between the plan outlined or determined by the provider and the client’s goals, needs, or prefer- ences. one way of looking at Joel’s situation is that he really doesn’t want a job and is just going through the motions—perhaps for some secondary gain. or perhaps nding a job isn’t as urgent for him as the provider thinks it is. We have noted this perspective when medical professionals we train share their frustra- tions about lack of client change. ey o en say something like “if they knew how important or urgent it is to their health for them to lose weight they would get on it AsAP.” Although believing that change is important certainly facili- tates change, it is not the only factor that should be considered when trying to understand slow progress. An MI-consistent way to think about this situation is that the change plan may not have captured the best strategies for changing or something has occurred that may have led the client to be more apprehensive about a particular change strategy. us, when experiencing slow progress, a more MI-consistent approach would include evoking information from the cli- ent about the factors that may be slowing down progress.

Proposed Strategy 1: Evocative Questions

A good MI-consistent way to discuss slow progress with clients is to step back from being directive (e.g., o ering advice, suggestions, or solutions) and use evocative questions. e use of evocative questions in these situations helps pro- viders elicit from clients their own evaluation of how they are progressing and what might be getting in the way. Adopting this approach can help avoid the expert trap and the righting re ex by keeping the relationship collaborative. It also communicates that the provider genuinely wants to understand the client’s perspective on the situation.

Example: MI-Consistent/Inconsistent Evoking

e following examples will illustrate MI-consistent and MI-inconsistent evoking when clients are progressing slowly.

Client statement: “I applied for one of the ve jobs you provided me last week. Getting a job is really important to me.”

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MI-Inconsistent: “Securing a job is important for you and yet you only applied for one job. Don’t you think it would be important to apply for all of the jobs I gave you?”

even though the provider begins with a re ection the response is MI-inconsistent. e re ection has a somewhat judgmental tone, primar- ily because of the word only. By using “only” the provider is communicat- ing that the client should have applied for more than one job. Additionally, the question is a closed question and a rhetorical question that is likely to engender discord versus facilitating discussion.

somewhat MI-Consistent: “I hear that nding a job is really important to you. At the same time, you applied for one of the ve jobs on the list. What was wrong with the other jobs?”

is statement is somewhat MI-consistent. e provider o ers a re ection that expresses appreciation for the ambivalence the client is experiencing. however, rather than stepping back to learn more about the client, the pro- vider remains focused on the jobs that were provided to learn why they didn’t work for the client. is approach could invite discord or sustain talk versus better understanding of the client’s motivations.

MI-Consistent: “I hear that nding a job is really important to you. At the same time, you applied for one of the ve jobs on the list. Perhaps I got a bit ahead of us with the list I gave you and didn’t spend enough time talking to you about your goals and expectations. If it’s okay with you, I’d like to learn a bit about what worked for you and what didn’t with the plan we developed for you to nd a job.”

is statement is MI-consistent for several reasons. e provider begins with a double-sided re ection that highlights the client’s desired goal and compares that with the progress. ere is no judgment in the re ection; the provider simply highlights what the client has said. e provider then admits to possibly taking an expert role and jumping ahead of the client in the plan. is allows for the provider to then transition back to eliciting from the client his perception of how well or not the plan unfolded. rough this the provider communicates collaboration and wanting to understand the client’s evaluation of the implementation of the plan.

Proposed Strategy 2: Assessing Importance and Con dence

As clients progress through change plans, the importance of the change and their con dence in their ability to make the change may wax and wane as they are faced with new goals, tasks, or obstacles. For example, in treating clients with obsessive-compulsive disorder, I (MM) noted that these clients o en experi- enced reductions in importance and con dence as treatment progressed. As fur- ther outlined in chapter 6, although they are highly e cacious, exposure-based treatments for obsessive-compulsive and related disorders require clients to complete practice exercises that can result in transient intense anxiety and other

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negative emotions. us, it is not uncommon for clients to express ambivalence about doing new exposures in their treatment even if they have already success- fully completed related exposures. In part this seemed due to their anxiety and desire to avoid—thus reducing the importance (e.g., “I’d rather just live with this illness than do this treatment.”). however, I also noted what seemed to be a lack of con dence in the ability to do the exposure (e.g., “I want to do this. I just don’t think I can go through with it today.”). e mantra at the treatment facility was “just do the exposure and it will get better”—a common behavior therapy response. Although the statement is true, this approach o en can lead to slower progress and impasses in treatment. By assessing importance and con dence when progress slows, a provider can engage the client in a discus- sion, learn what is behind the slow progress, and even help the client resolve any importance or con dence barriers. Remember that ambivalence can return when someone is actively changing. one way it might present itself is through slow or slowed-down progress.

Example: MI-Consistent/Inconsistent Reassessing Importance and Con dence

e following examples will illustrate MI-consistent and MI-inconsistent questions for reassessing importance and con dence when clients experi- ence slow progress.

Client statement: “I applied for one of the ve jobs you provided me last week. Getting a job is really important to me.”

MI-Inconsistent: “So is getting a job really important to you?”

is provider statement is MI-inconsistent for two reasons. e provider’s emphasis on “really” communicates that he does not believe the client’s statement about importance. e question appears to be an accusation and does not assess how important nding a job is for the client. is statement by the provider is more likely to elicit a defensive response from the client as the provider is “calling out” the client and challenging him. e question is also a closed question. By asking the question in this way, the provider is unlikely to learn about the factors that are impeding progress.

somewhat MI-Consistent: “On a scale of 1 to 10, how con dent you are in your ability to search for a job?”

is response is somewhat MI-consistent. Now that the provider under- stands how important nding a job is to the client, he or she uses a scaling question to assess his con dence in his ability to nd a job. however, the provider jumps to a scaling question on a di erent topic (con dence versus importance) without rst re ecting what the client has said. is is a missed opportunity to express empathy. If done repeatedly, this could lead the cli- ent to believe the provider is not really interested in what he or she is saying, or to a question and answer trap in which the client passively responds to provider questions.

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MI-Consistent: “Finding a job is something that is important to you. is week you were able to apply for one of the ve jobs on the list. I wonder if you can share with me, on a scale of 0 to 10, how con dent you are in your ability to search for a job. [Client response: “About a 5.”] So you have some con dence to search for a job. What makes your con dence a 5 and not a 3?”

MI-Consistent: “Finding a job is important to you and you were able to apply for one of the ve jobs on the list. Perhaps you can tell me on a scale of 0 to 10 where the importance of nding a job is for you at this point? [Client response: “About a 7.”] So it is important to you but not of the highest importance at this time. What would need to happen for it to be a 9 or 10 and not a 7?”

ese statements are MI-consistent for several reasons. e provider uses re ection to highlight that the client was able to apply for one job on the list while also indicating it was one of ve positions. ere is no judg- ment in these re ections and they restate what the client has said. e provider’s statements focus on the client and do not introduce his own interpretations of the situation. ere is no assumption of how important or con dent the client is in the plan. Further, the questions are presented in a way that does not imply the client is lying or that the provider doesn’t believe the client.

Proposed Strategy 3: Revise the Change Plan

sometimes slow progress might be an indicator that the original change plan that was developed (and to which the client committed) may not have been the best possible plan. is can be the case for several reasons: perhaps the provider was not fully collaborative, or all of the possible options and barriers were not considered, or the client didn’t envision what it would look like when they began the plan. Regardless of the reason, slow progress by a client may signal the need to revisit the change plan to determine what aspects of the plan, if any, need to be revised to facilitate change. stepping back to review the change plan when prog- ress is slow communicates to clients that the provider and client are “in this pro- cess together” and that the provider is genuinely committed to helping the client develop the best personal plan of action. is approach is more MI-consistent than asking, “Why aren’t you working on this plan? You agreed to it.” Remember from chapter 2 that we need to respect the expertise and autonomy of the client and we want to work with them to determine what change is best and how it is best to change for each client.

Example: MI-Consistent/Inconsistent Revising a Plan

e following examples will illustrate MI-consistent and MI-inconsistent revising of the change plan.

Client statement: “I applied for one of the ve jobs you provided me last week. Getting a job is really important to me.”

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MI-Inconsistent: “ is plan doesn’t seem to be working for you. Is the plan wrong?”

e provider acknowledges that the plan may not be working for the client. What makes this statement MI-inconsistent is the closed question. Remember to be MI-consistent providers want to use more engaging and eliciting ques- tions. A closed question rarely accomplishes this goal. Additionally, the ques- tion has the potential to engender some defensiveness in the client.

somewhat MI-Consistent: “You accomplished part of your plan and struggled with other parts. What needs to change to make the plan work better for you?”

e provider a rms that the client made some accomplishments in the plan which is MI-consistent. however, the provider also emphasizes the dif- culty the client had with the plan by closing the re ection with that point. is re ection combined with the question could communicate some judg- ment, though subtle, about the client’s e orts and invite discord.

MI-Consistent: “You accomplished part of the plan this week. In moving for- ward it might be helpful to revisit the change plan to see if there are things that need to be added, removed, or revised to strengthen it for you.”

is provider statement has several aspects that make it MI-consistent. e provider re ects the client’s statement about progress on the plan. Additionally, there is a strength-based emphasis (i.e., “you accomplished”). Placing emphasis on what was accomplished potentially reduces the chance of eliciting defensiveness. Further, the provider raises the idea, without any judgment, of looking at the plan to see what might need to be changed. e statement also attempts to engage the client in the process of reviewing the plan. see the “evaluating the Current Plan” box for some questions you could use in reevaluating the change plan.

Evaluating the Current Plan

What have you learned from trying to implement this plan? What aspects of the plan are working?
What parts of the plan are not working?
how is the plan helping you meet your goals?

What should we add/remove from the plan? What should we revise in the plan?

Proposed Strategy 4: Emphasizing Personal Control

Ultimately what clients decide to do with their change plans is up to them. As we have mentioned multiple times in this book, we can’t make people do what

 

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they do not want to do. is fact also applies to the speed at which someone progresses on her or his change plan. us, it is important for us to remember, in remaining MI-consistent, that clients are in control of their change and the pace at which they change. In other words, we need to recognize that it is the client’s change timetable and not ours. Ultimately, it is up to our clients how fast or slow they change. us, we need to be mindful of the importance of client autonomy and personal control when client progress is slow to keep us from pressuring clients. It is also something of which clients should be reminded in the face of slow progress.

Example: MI-Consistent/Inconsistent Emphasizing Personal Control

e following examples will illustrate MI-consistent and MI-inconsistent emphasizing personal control for slow-progressing clients.

Client statement: “I applied for one of the ve jobs you provided me last week. Getting a job is really important to me.”

MI-Inconsistent: “It is your choice how many jobs you apply for but we need to get you a job.”

e attempt to emphasize personal control was thwarted by the end of the provider’s statement—“but we need to get you a job.” is minimizes the client’s personal control and choice in the situation by expressing some- thing that has to happen. Further, by adding the message “you need to get a job,” the provider is increasing the chances the client will engage in con- versation about why it is hard to get a job or when the jobs or strategies sug- gested will not work. In other words, this statement is likely to elicit sustain talk and possibly discord.

somewhat MI-Consistent: “Finding a job is really important to you. Only you can make this happen.”

e provider begins with a re ection highlighting the importance of get- ting a job to the client and emphasizes personal control. however, the pro- vider’s attempt to emphasize personal control could elicit sustain talk or discord as there is a hint of judgment in the statement.

MI-Consistent: “You are here because you want to nd a job and indicated that is really important to you. Nobody knows you and what jobs t you bet- ter than you do. And nobody other than you can decide how many jobs you apply for.”

e provider begins the statement by re ecting the client’s statement about the importance of nding a job. Further, the provider makes a statement that emphasizes that the client is the expert on himself and that he is in control of his life. is includes the provider also suggesting that the pace of nding a job is completely within the client’s control and not the provider’s. e provider avoids including his perspective on how many jobs the client should apply for or how fast he should seek opportunities.

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CLINICAL CHALLENGE 2: LAPSES AND RELAPSES

Description

It is common for clients who are changing to experience a slip or lapse, an ini- tial setback during which they return to a previous behavior that is counter to their change e ort (Marlatt & Witkiewitz, 2005). once they experience this setback, many clients experience a relapse or a total return to the problematic patterns they were trying to change (Connors et al., 2013). ink for a moment about New Year’s resolutions. At the start of every year, countless people ock to tness centers with the goal of increasing their physical activity and becom- ing healthier. For some this goal is actualized; however, for many others work toward their goals tends to wane a er weeks or months only to be revisited again with the next New Year’s resolution. us, setbacks, lapses, and relapses are common occurrences when changing. Regardless of this fact, we as providers o en become discouraged when a client lapses or relapses. As a result, we o en respond in a fashion that is MI-inconsistent, especially in some contexts where relapse is very common. Miller, Forcehimes, and Zweben (2011) comment how it seems strange that many treatment programs and providers respond to lapses and relapses in a punitive fashion when setbacks are so common when changing. eir point is a good one: if we conceptualize slips and relapses as part of the change process, why not respond in a supportive fashion that aims to reengage the client in the change process? We certainly do not respond in a punitive fash- ion when someone’s cancer reoccurs.

example: Elaina is a 35-year-old woman who is married and has three children. She gained 75 pounds when she was pregnant with her third child 3 years ago. en she learned that she had hypertension and her physician recommended she lose weight and change her lifestyle. About a year ago she began to work with a dietician, a personal trainer, and a behavioral special- ist to develop a healthier lifestyle. For 7 months Elaina has been successful in increasing her physical activity and modifying her diet, which led to a 25-pound weight loss. However, she recently stopped exercising and returned to old eating patterns during the holiday season. She also began to avoid her counseling sessions with her team. When she nally talked with her behavior specialist, she indicated she felt terrible about her relapse and that her team would be mad at her.

elaina’s experience is not uncommon when people are attempting lasting change. one explanation for what might have happened is the abstinence violation e ect, in which clients who have made change think they “fell o the wagon” by reengaging in a problem behavior (gaughf & Madson, 2008). Adopting a punitive stance as a provider can reinforce the abstinence vio- lation e ect and lead a client to disengage from the provider or even from

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considering reengaging in change. however, remembering the stages of readi- ness to change and maintaining an MI-consistent focus can certainly help providers react and respond to these types of setbacks in clients and reengage them in the change process. here are some strategies for working with clients who reengage in problem behaviors.

Proposed Strategy 1: Providing Information

Providing information about the potential for lapse and relapse can be very ben- e cial in helping clients appreciate the waxes and wanes associated with making lasting change. educating clients about the high-risk situations and discussing them is a valuable aspect of relapse prevention (Marlatt & Witkiewitz, 2005). however, when clients are actively making change or have sustained a change for a period of time, there can be a tendency for providers to adopt an expert role and actively prescribe what the client should do in high-risk situations. is approach would be inconsistent with MI. In chapter 3 we discussed the cyclical process of exchanging information called elicit-provide-elicit as an MI-consistent method for providing information (Rollnick, Miller, & Butler, 2008). By using elicit-provide-elicit, a provider can discuss the potential for lapses and relapses and discuss what happened during a lapse or relapse event. is approach allows the provider to explore lapses and relapses in a collaborative way that is engaging and invites clients to be the expert commentators on their situation.

Example: MI-Consistent/Inconsistent Providing Information

e following examples will illustrate MI-consistent and MI-inconsistent providing information.

Client statement: “I don’t know what happened—before I knew it 2 months went by and I hadn’t exercised. en I just ate all the holiday goodies ignoring my diet plan.”

MI-Inconsistent: “ e holidays are a di cult time for many people to main- tain healthy lifestyles. You really need to remember your plan and how it can help you avoid those temptations.”

is statement is MI-inconsistent for several reasons. First, the tone of the provider’s statement is somewhat judgmental and is likely to elicit responses from the client justifying why the setback happened. second, the provider adopts an expert role and jumps into providing information about relapse. here the provider is missing an opportunity to engage the client as a collaborator in identifying what happened that led her to resume her eating behaviors and not exercising. Finally, the provider prescribes what the client needs to do to avoid a relapse. however, the provider is missing an opportunity to gauge the client’s interpretation or reactions to the information provided.

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somewhat MI-Consistent: “You ran into some di culties with your plan over the holidays that you see as a setback. You may remember from past expe- riences that the holidays can be a particularly di cult time—we call them high-risk situations. At these times one’s health plan is particularly impor- tant. How does that information match up with your experiences?”

is statement is somewhat MI-consistent. e provider begins with a re ection that communicates empathy and understanding of the client. e provider checks in with the client again a er providing information. however, the provider does not elicit from the client prior to provid- ing information and decides what information to provide without rst checking what the client already knows from her experience with previ- ous change e orts. ere is a potential that the client may respond with sustain talk.

MI-Consistent: “You ran into some di culties with your plan over the holi- days that you see as a setback. From your past experiences trying to make changes, what do you know about di culties changing? [Waits for cli- ent response]. If I might share with you, the holidays can be a particularly high-risk time for folks trying to change their eating and exercise behaviors for a variety of reasons, ranging from stress to tempting foods to being very busy. How does that information match up with your experiences?”

is statement is MI-consistent for several reasons. First, the statement begins by re ecting the client’s conceptualization of the problem, which validates her experience. ere is also no judgmental tone and the re ection is simply reiterating the facts as perceived by the client. Next, the provider o ers some information about how the holiday season can be di cult for a lot of people and provides some potential reasons why this is the case. Finally, rather than telling the client what she needs to do, the provider elic- its the client’s interpretation of the information. is approach can reduce the emotionality of the situation, communicate a matter-of-fact mind-set and facilitate a focus on where to go from here.

Proposed Strategy 2: Reassess Importance and Con dence

Recognizing lapses and relapses as a natural part of the lasting change process can help a provider refocus on building motivation for reengagement in active behavior change. us, a provider may need to revisit the client’s motivation for changing (Miller et al., 2011). one approach to begin this discussion is reex- amining how important the change is to client and how con dent they feel in their abilities to change a er a lapse or relapse. In other words, a provider can use the importance and con dence questions to begin assessing whether something has changed for the client that may have led him or her to resume problematic patterns.

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Example: MI-Consistent/Inconsistent Reassessing Importance and Con dence

e following examples will illustrate MI-consistent and MI-inconsistent scaling questions for reassessing importance and con dence clients who lapse or relapse.

Client statement: “I don’t know what happened. Before I knew it 2 months went by and I hadn’t exercised, then I just ate all the holiday goodies, ignor- ing my diet plan.”

MI-Inconsistent: “So is your diet and exercise still important to you?”

is provider statement is MI-inconsistent for two reasons. First, the use of a question like this, especially in the context of a relapse, is somewhat judgmental and is likely to engender discord as it can be perceived as an accusation versus assessing how important resuming change is to the cli- ent. second, this is a closed question, and given the tone of the question may likely elicit a short response versus a longer response. us, by using this question the provider has missed an opportunity to engage the client in exploring her hesitancy to change or identify why the importance of chang- ing has reduced.

somewhat MI-Consistent: “How important is changing to you right now?”

is statement is somewhat MI-consistent. e provider o ers an open question that invites the client to share her perspectives. however, by jump- ing straight to a question, the provider misses an opportunity to express empathy, provide support, and/or a rm a client who likely feels disap- pointed in herself. Additionally, while the open question used is not neces- sarily a “bad” question, in this particular case it may imply that the provider believes the client’s lapse may be an indication that she is not serious about change. is could lead to defensiveness.

MI-Consistent: “You had a lot of things come up in the past few months with the holidays that have gotten in the way with your change plan. I wonder, for you at this point on a scale of 0 (not at all important) to 10 (the most important thing) how important it is to you to resume your change? [Client response: “About an 8.”] So it is fairly important to you to resume changing. What makes the importance an 8 and not a 6?”

MI-Consistent: “You had a lot of things come up in the past few months including the holidays that have gotten in the way with your change plan and le you discouraged. At this point on a scale of 0 (not at all con dent) to 10 (completely con dent), how con dent are you in your ability to resume your change? [Client response: “About a 4.”] So while it is important to you, perhaps based on your recent experience, you are not as con dent in resuming change. What would need to happen for it to be a 7 and not a 4?”

ese statements are MI-consistent for several reasons. First the statements begin with a re ection that validates the client’s experience with the relapse.

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ey are matter of fact with no judgment and simply restate what the cli- ent has experienced with an added emotion. Next, the statements focus on assessing the client’s perspective of how important change is and how con- dent she feels in resuming change. ere is no assumption that the client is ready or con dent in resuming change. By using a scaling question to focus on the importance of the behavior the provider gets a better sense of where the client is at in resuming her change or not. Finally, the follow-up ques- tion is likely to guide the client to provide change talk by discussing why resuming change is important and how she can become more con dent.

Proposed Strategy 3: Looking Back

once clients relapse, they may be preoccupied with the relapse and perhaps whatever has changed that has led to the return to problem behaviors. Possibly their motivation has changed because they do not recall what things were like while they were actively changing. erefore, as part of building motivation to reengage in change a er a relapse, it may be valuable to look back to the time when the client was actively changing and compare that to their current state.

Example: MI-Consistent/Inconsistent Looking Back

e following examples will illustrate MI-consistent and MI-inconsistent looking back for clients who relapsed.

Client statement: “I don’t know what happened—before I knew it 2 months went by and I hadn’t exercised. en I just ate all the holiday goodies, ignor- ing my diet plan.”

MI-Inconsistent: “Do you remember what it was like when you were actively changing before you relapsed?”

is statement is MI-inconsistent because the provider uses a closed ques- tion. e question also could be perceived by the client as judgmental. Additionally, the provider falls into the labeling trap by using the word “relapse”. labeling words can elicit discord from clients who feel judged.

somewhat MI-Consistent: “You are frustrated that a er you made progress you had a return to previous behavior. Perhaps we can take a moment to look back on what led up to the setback in your plan.”

e provider o ers a nice re ection to communicate empathy. Traditionally, however, the looking back strategy in MI focuses on a time when the client was not engaged in the problem behavior. us, the application of looking back in this way is only somewhat MI-consistent, as it might focus the cli- ent on talking about the problem versus what it was like when the client was changing so she can regain her motivation.

MI-Consistent: “You are frustrated that a er making much progress you stopped exercising and started eating the holiday goodies. I wonder if we can

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take a moment to look back to when you were following your exercise and eating plan to see if it gives us any clues about how you might best be able to get back on track now should you want to.”

is provider statement has several aspects that make it MI-consistent. e provider re ects the client’s feelings about the relapse. In this re ection the provider uses the client’s own words and avoids labeling the behavior. e provider uses looking back in an MI-consistent way by looking back to when the client was not experiencing the problem to compare it to her current state.

Proposed Strategy 4: Decisional Balance

given that a lapse or relapse is a sign that clients likely shi ed in their readiness to change, it may be valuable to explore the pros and cons of changing or con- tinuing problematic patterns. Remember from chapter 3 that an MI-consistent approach to decisional balance involves exploring all sides of the change versus advocating for or focusing on the pro-change side of ambivalence. Pro-change advocacy by the provider will place clients in a position to advocate for the status quo. us, even though clients have been successfully involved in maintaining change, we need to recognize that something may have occurred to tip the scale in favor of resuming problematic patterns. For instance, Miller and colleagues (2011) suggested that a client’s successful change of one problem (in their exam- ple, substance use) can lead to the realization that other problems exist. is realization could lead to falling back into problem patterns. erefore, you may need to guide the client through reevaluating changing or not.

Example: MI-Consistent—Inconsistent Decisional Balance

e following examples will illustrate MI-consistent and MI-inconsistent decisional balance for a client who has relapsed.

Client statement: “I don’t know what happened. Before I knew it 2 months went by and I hadn’t exercised. en I just ate all the holiday goodies, ignor- ing my diet plan.”

MI-Inconsistent: “So you had a relapse and it will be important to get back to your plan so you can continue losing weight and keep your blood pressure under control. Not resuming change will only make your health worse.”

is is de nitely an attempt at discussing the bene ts of change and nega- tives of not changing; however, it is MI-inconsistent. e provider has adopted an expert role and is providing the reasons why resuming change is bene cial and why not changing is a problem. is response will likely place the client in a position to defend not changing by expressing the bene ts of staying the same and the cons of changing. In other words, the provider is arguing for change, which is MI-inconsistent.

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somewhat MI-Consistent: “You are concerned about resuming some behav- iors you are trying to change. What are some of the pros and cons to resuming those behaviors?”

is response is a somewhat MI-consistent attempt at a decisional balance. e provider begins with a re ection that expresses understanding and empathy. however, in exploring the decisional balance the provider only elicits the pros and cons of resuming problem behaviors and ignores the pros/cons of resuming change. is approach may guide the client to only discuss the problem behaviors and avoid addressing change.

MI-Consistent: “You had a brief period of time where you resumed some of the behaviors you were changing. at concerned you. What might be some of the bene ts and drawbacks of staying the way you are now? What might be some of the good things and not-so-good things about resuming your change e orts?”

is response is MI-consistent for several reasons. e statement begins with a restatement of what the client said. e statement also added that the client was concerned about the situation, which emphasized the unspo- ken emotion in the client’s statement. e provider then facilitates the deci- sional balance by rst asking about the client staying the way she currently is in her change e ort. Next, the provider asks the client about resuming her change e orts. At no time does the provider advocate for one side or the other (i.e., changing or staying the same), which is an important feature of a decisional balance.

Proposed Strategy 5: Eliciting and Af rming Strengths

ere can be a tendency when clients experience a lapse or relapse for them to focus on the mistakes they made leading to the setback, which can result in nega- tive a ect and more avoidance (DiClemente, 2003). however, before the lapse or relapse they were actively making changes. erefore, there likely were strengths exhibited and successes achieved. Although a provider will probably eventually need to discuss the situation that led to the lapse or relapse, it is also valuable to elicit from the clients their successes and what strengths helped them in their change e orts.

Example: MI-Consistent/Inconsistent Eliciting and A rming Strengths

e following examples will illustrate MI-consistent and MI-inconsistent eliciting and a rming strengths for clients who relapse.

Client statement: “I don’t know what happened. Before I knew it 2 months went by and I hadn’t exercised. en I just ate all the holiday goodies, ignor- ing my diet plan.”

MI-Inconsistent: “You didn’t stick with the plan. What happened?”

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is type of response is commonly used by providers in an attempt to better understand a relapse. however, the provider is not commenting on the cli- ent’s success and not eliciting strengths from the client. Additionally, while the intention may be to be supportive, this type of response could leave the client feeling more discouraged. It clearly communicates a failure in prog- ress. Further there is the potential that the provider commenting on the suc- cess could lead to a response from the client focusing on the setback. Finally, the focus on what happened can lead the client to focus more on the problem that lead to the relapse including her de cits versus eliciting strengths.

somewhat MI-Consistent: “You seem a bit discouraged in your behavior the past few months. It could happen to anyone. Don’t be too hard on yourself. I know you can get back in there and do it again!”

is statement is somewhat MI-consistent. e provider begins with a re ection that expresses empathy. e provider then seeks to a rm the client. however, rather than commenting on the client’s strengths or past successes, the provider focuses on his or her belief that the client is capable. is sort of cheerleading is an example of the righting re ex. is response is likely to elicit the opposite of change talk from the client in an attempt to correct the provider.

MI-Consistent: “You seem a bit discouraged in your behavior the past few months. At the same time you made the decision to come back here which suggests persistence. Perhaps you can share with me what you learned about yourself during the seven months when you were very successful with your plan?”

is statement is MI-consistent for several reasons. First, with the statement re ects an emotion the client experienced as a result of the relapse. Next, the provider a rms the client’s return. Finally, the provider seeks to elicit from the client her strengths and what she had learned about her success in making a change prior to the relapse.

Proposed Strategy 6: Reframing

A return to problem patterns can also be seen by clients, and some providers, as a failure in the change e ort. is view can lead to a variety of emotional, cog- nitive, and behavioral responses. emotionally clients may feel guilty, sad, and anxious. Clients may also think of themselves as failures or that they can never change their problems. Behaviorally, clients may avoid professionals who were involved with their change initiatives. Unfortunately, these emotional, cognitive, and behavioral responses are more likely to entrench clients in not changing. Reframing what a lapse or relapse is can help to facilitate di erent emotional, cognitive, and behavioral responses that are more conducive to changing. In fact, Miller and colleagues (2011) suggest referring to a lapse or relapse as a behavior

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or choice. As we mentioned earlier, conceptualizing a return to problem behav- iors as a natural part of the change process can help you and clients reframe the setbacks in a way that can help you better understand the setbacks and problem solve what to do next.

Example: MI-Consistent/Inconsistent Reframing

e following examples will illustrate MI-consistent and MI-inconsistent reframing for clients who experienced a relapse.

Client statement: “I don’t know what happened. Before I knew it 2 months went by and I hadn’t exercised. en I just ate all the holiday goodies, ignor- ing my diet plan.”

MI-Inconsistent: “You had a relapse. at is a normal part of changing.”

is statement represents an attempt at reframing because the provider indicates the relapse is part of changing. however, it is MI-inconsistent because the provider uses the term “relapse,” which is a label, thus falling into the labeling trap. Using a label such as relapse could evoke discord from in the client. Additionally, the provider takes on an expert role in that the provider assumes he or she has a full understanding of why the client is having problems without seeking to evoke additional informa- tion about how or why the client got o track.

somewhat MI-Consistent: “In my experience setbacks are a natural part of changing, and I think it is great that you came in today as it shows me how committed you are to making a lasting change. I am proud of you for that.”

is response is supportive and a reframe of the relapse and may appear MI-consistent. however, it is only somewhat MI-consistent for several reasons. First, the provider falls into an expert trap by o ering informa- tion without emphasizing the client’s personal control or announcing or inviting the sharing of information. Additionally, the provider violates the rules for a rmations by using “I” and communicating a message that “you have pleased me.”

MI-Consistent: “ ank you for coming today. You recently chose to step away from your change plan and became discouraged in light of 7 months of suc- cess. It seems to me that your situation provides us a good learning opportu- nity. What are your thoughts about that?”

is statement is MI-consistent for several reasons. First, the statement begins with an a rmation by reframing the client showing up as a positive given the relapse. Next, the provider avoids labeling and emphasizes that the client made a choice which highlights personal control. Finally, by sug- gesting that the provider and client have a learning opportunity reframes the relapse as a part of the change process from which they can learn.

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CLINICAL CHALLENGE 3: OVERLY AMBITIOUS EXPECTATIONS

Description

A type of challenge that can in uence momentum and can be uniquely demand- ing is the client with overly ambitious expectations. Clients may have expec- tations that changing will require little e ort or that there is a magic cure or technique that they can use to change. When watching television, you can see advertisements for a variety of quick-change tools ranging from clothing that “melts away fat” to energy-increasing or weight-reduction pills to exercise equip- ment that require minimal actual physical activity to get back “that high school body.” For these reasons, as well as many others, many people are seeking change initiatives that require little e ort to change. us it is not surprising that we are o en asked, “What do I do with a client whose goals are unrealistic or unattain- able in our work together?”

e client with overly ambitious expectations poses an interesting dilemma for many providers. Providers may feel a strong urge to educate that client and pro- vide suggestions for more realistic goals based on their knowledge, experience, and understanding of the research related to changing a particular problem. For many clinical approaches this would be perfectly appropriate. We remember our clinical training and the rules for developing change goals, especially the rule for keeping goals realistic and manageable to foster success. however, adopting this expert role is inconsistent with MI. In fact, informing clients that their goals are unrealistic or less likely to be obtained and prescribing alternate goals may actu- ally reduce client motivation rather than helping them to develop more attain- able change goals. us, the dilemma is how to be MI-consistent and to help clients manage their expectations for change, especially when they are overly ambitious and unrealistic.

example: Brandy is a married woman who initiates individual therapy with concerns about her marriage and lack of communication with her husband. She has been married for 10 years and reports that her relationship with her husband has become increasingly worse since the couple had three children. Speci cally, Brandy reported that when she tries to initiate conversation with her husband he becomes nonresponsive and withdraws from her even fur- ther. She has read several relationship books and has not found the perfect solution. erefore, she has entered therapy to learn the best way to get her husband to engage with her. She wants the therapist to provide her with the method to solve her relationship problem.

As psychologists, we o en encounter clients who have certain expectations about what we can o er to help them change. ese expectations o en relate to what “we [the provider] are going to do to change them.” We can certainly appreciate where this expectation comes from as many medical interventions,

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especially those for acute illnesses, rely primarily on a health care worker doing something to x a problem. however, this model is generally not applicable to prevention and management of chronic illness and other more complex prob- lems. e best solution to these types of problems is rarely achieved by a provider just “doing something” to the client. Instead, the solutions requires clients to “do something” to change.

example: Earl is a single father whose son Craig, age 10, was diagnosed with asthma 3 years ago. ey are seeking counseling at the referral of Craig’s phy- sician as he is not managing his asthma very well and has been admitted to the hospital three times in the past 6 months for asthma-related problems. Earl reports that Craig is not adhering to medical recommendations for man- aging his asthma and he is at a loss for what to do with Craig. Earl reports that he works 10 to 12 hours per day and that he is not available to help Craig keep track of his medications or monitor all of his behavior. Earl gured he would bring Craig for counseling as that would help “straighten him out” and get him to follow medical directions.

Finally, based on our society’s focus on the “quick x” clients may have unreal- istic expectations about outcomes associated with their change and how quickly positive change will occur. ey may think that by losing weight their relation- ships will improve or that simply attending nutrition counseling will cure their diabetes.

example: Steve is diagnosed with obesity, hypertension, and diabetes. He has had di culties managing his weight since he was a little boy and has been under the care of his physician for the past 5 years. Steve, like many other people, has dieted on and o throughout his life, losing some weight only to gain it back plus some additional weight. Steve has become increasingly con- cerned about his weight and the associated health e ects as he recently had a mild heart attack. In fact, he has expressed his commitment to losing weight. However, his expressed goal is to lose 50 pounds in the next month as he wants to lose 150 pounds by his birthday in 3 months. He is seeking guidance from a weight loss specialist on how best to meet this goal.

similarly, individuals who have made some progress in changing may over- estimate what their progress means and decide that they are have completed change and are cured. expectations that small gains equal complete cure can complicate that person’s change initiative.

example: Shelia is early in recovery from a drug addiction that she has strug- gled with for 7 years. She has been in a residential substance abuse treatment program and hasn’t used in 3 weeks. Since entering the program, Shelia has been engaged in the treatment and is showing signs of recovering physically from her addiction. Shelia is making good gains in treatment and recognizing

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how she is improving. In a recent conversation; she stated that she believes she now has mastery over her addiction (o en referred to as the “pink cloud e ect”). She indicates that since she is doing well she wants to spend more time away from the treatment facility.

Whatever the reason for clients developing overly ambitious expectations about change, it seems to create a unique challenge to remaining MI-consistent. is challenge involves how to remain MI-consistent and at the same time help clients develop more realistic expectations for change initiatives. In part, this challenge arises from the righting re ex (see chapter 2) which causes provid- ers to have a natural tendency to want to correct clients. us, one important thing a provider can do to remain MI-consistent in working with unrealistic expectations is to resist the righting re ex. e following are some strategies that can help a provider resist the righting re ex and remain MI-consistent when addressing unrealistic goals.

Proposed Strategy 1: Asking Permission to Provide a Concern

When discussing an unrealistic goal in an MI-consistent fashion, it is imperative that the provider not directly assert his or her expert status by rejecting the cli- ent’s goal or by o ering a new goal. Many providers may feel compelled to jump to providing facts about change and education about the change process as a strategy for helping clients modify their expectations. In fact, some approaches to helping call for this education at the outset of any change initiative or goal set- ting. In contrast, MI encourages clients to remain empowered while negotiating their change. Directly educating clients may foster a climate of passivity in the client-provider interaction. however a provider can certainly share information or even a concern and remain MI-consistent.

As discussed in chapter 3, information can be shared with clients in an MI-consistent way. First, a provider can be MI-consistent by asking permission to share some information or announcing that he or she has some information that he or she would like to share. Whether the provider asks permission or announces that he or she would like to share some information, the provider is communi- cating that he or she values the collaborative relationship with the client, accepts their opinions about the process of change, and wants to be engaged with the client as a partner in the change process. Another MI-consistent approach to pro- viding information is to emphasize the client’s personal control to decide what to do with the information provided. In addition to communicating dedication to collaboration, emphasizing personal control communicates that the provider accepts the client and respects his or her autonomy to decide to do what he or she thinks is best.

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Example: MI-Consistent/Inconsistent Sharing Information or Concern

e following examples will illustrate MI-consistent and MI-inconsistent strategies for sharing information or a concern.

Client statement: “I believe I have really progressed in treatment and am ready to spend more time away from the facility. I have this addiction under control now.”

MI-Inconsistent: “You have been here for three weeks and you have made progress. Physically the drug has nally been eliminated from your body and you are feeling better. ere is a lot of work you need to do to more fully recover from your addiction and more time away from the facility puts you at risk for relapse.”

is statement provides the client with information about the physiological aspects of recovery and that recovery is an ongoing process that takes time. Although it is not overly confrontational, it is MI-inconsistent and likely could engender discord. In particular, the provider adopts the role of an expert who is imparting the “correct” knowledge about the situation. e likelihood that the client will push back against this statement is high.

somewhat MI-Consistent: “You have made some progress and are feeling good about your success in treatment. One thing that concerns me is that it is common for clients to feel mastery over their addictions early in treatment and want to take more time away from the facility. Does that seem to t with your experience?”

is statement is somewhat MI-consistent and re ects a comment o en o ered by supportive providers. however, it is not fully MI-consistent because the provider does not announce the o ering of information or seek permission. similarly, the provider attempts to elicit a client response to this information with a closed question.

MI-Consistent: “You are noticing some improvements in how you feel and in your treatment—so much so that you feel ready to spend more time away from the facility. If it is okay with you, I would like to share some informa- tion about the recovery process for your consideration. [Waits for client response]. One thing that is common in early recovery is a sense of mastery over one’s addiction when you begin feeling better physically. While it is a sign of improvement, I get concerned for my clients as this feeling can lead to decisions, like ending treatment, which can increase risk for resuming the addiction.”

is statement is MI-consistent because the provider begins by re ecting the client’s statement, which communicates empathy. Next the provider asks for permission to share the information and emphasizes the client’s personal control to decide versus simply providing the information as an expert. Finally, the provider provides the information in a non-judgmental

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way and owns the concern about the situation as his own, which also com- municates compassion for the client.

Proposed Strategy 2: Use Evocative Questions

Utilizing clients’ expertise and eliciting from them information that can develop more realistic expectations can be a valuable tool to remain MI-consistent. As mentioned in chapter 2, clients are the experts on their lives and better under- stand their past experiences. By selectively using questions, a provider can draw out from clients how their experiences may or may not relate to their current expectations. By using evocative questions a provider avoids the righting re ex, respects client autonomy, and collaborates with the client versus acting as an expert. Clients likely have attempted similar change initiatives in the past and have knowledge about what worked and did not work and how realistic or unre- alistic their current expectations may be. us, by asking evocative questions the provider can utilize the client’s experiences and expertise to help the client think more realistically about their expectations.

Example: MI-Consistent/Inconsistent Evoking

e following examples will illustrate MI-consistent and MI-inconsistent evoking for clients who have unrealistic expectations.

Client statement: “I believe I have really progressed in treatment and am ready to spend more time away from the facility. I have this addiction under control now.

MI-Inconsistent: “Do you really think your addiction is under control?”

is question is MI-inconsistent for two reasons. First, it is a closed ques- tion. evoking questions tend to be open ended to invite the client to respond more thoroughly and freely. second, the question is a rhetorical question that also has a value judgment to it. us, the question is highly likely to engender discord.

somewhat MI-Consistent: “You are really committed to your recovery and recognize the gains you have made. Based on what you have learned about recovery in this program, what else do you need to do to recover?”

is statement is somewhat MI-consistent. e provider begins by o ering a re ection of how the client is feeling about their progress in treatment. Next the provider asks an open question to elicit information from the cli- ent about the recovery process in relation to goals. however, rather than exploring what the client has learned from previous experiences attempting recovery, the provider asks the question in the context of what the client has learned from the treatment facility. is approach fosters an expert role on behalf of the provider and the facility and communicates that they have the expertise and not the client.

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MI-Consistent: “You are really committed to your recovery and recognize the gains you have made. Tell me about your past attempts to at recovery and what you know about how recovery works for you. How might that informa- tion help inform your choices at this time.”

is statement is MI-consistent because the provider begins by re ecting the client’s statement, which communicates empathy. Next, rather than providing information about appropriate recovery, the provider uses the client’s previous experience with recovery to invite her to be the expert on her experience. Finally, the provider uses eliciting to connect the client’s previous experience and knowledge about herself to current decisions.

Proposed Strategy 3: Elicit-Provide-Elicit

An MI-consistent approach that combines the rst two proposed strat- egies is the elicit-provide-elicit strategy. As discussed in chapter 3, the elicit-provide-elicit strategy fosters client engagement in sharing information and draws out information and reactions from the client. elicit-provide-elicit invites clients to share their knowledge and to interpret the information/con- cern shared. is strategy also allows a provider to better understand what facts and myths the client already believes about the change initiative, and helps the provider create a better understanding by lling in the gaps or cor- recting misinformation. In other words, the provider knows what they client already knows and doesn’t know so the information provided can be more focused.

Example: MI-Consistent/Inconsistent Elicit-Provide-Elicit

e following examples will illustrate MI-consistent and MI-inconsistent elicit-provide-elicit for clients who have unrealistic expectations.

Client statement: “I really believe I have really progressed in treatment and am ready to spend more time away from the facility. I have this addiction under control now.”

MI-Inconsistent: “What we see in the research is that it is important to help you to learn how to better manage high-risk situations and that takes time.”

is provider statement is MI-inconsistent for two reasons. First, there is no eliciting from the client, and the provider jumps into providing informa- tion. second, the provider does not elicit the client’s response or interpreta- tion of that information. Finally, a statement such as this is highly likely to engender discord as it can be perceived as judgmental.

somewhat MI-Consistent: “You really want to succeed in your recovery. Tell me what you already know about successful recovery. [Waits for cli- ent to respond]. If I may add to your understanding, one thing we o en see that helps is learning new strategies for assisting and monitoring high risk

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situations, which includes gradually exposing people to these situations over time as they recover. Does that make sense?”

is response is a somewhat MI-consistent use of elicit-provide-elicit, but is not fully MI-consistent because the provider asked a closed question a er providing the information. is type of question invites only a brief response. is type of question also may subtly communicate the message “do you agree with me” and could invite passivity and less open sharing of reactions and interpretations of the information from the client.

MI-Consistent: “You really want to succeed in your recovery. Tell me what you already know about successful recovery. [Waits for client to respond]. If I may add to your understanding, one thing we o en see that helps is learn- ing new strategies for assisting and monitoring high-risk situations, which includes gradually exposing people to these situations over time as they recover. What are your thoughts about that?”

is statement is MI-consistent because the provider communicates empa- thy and reinforces the client wanting to recover. Next, before providing information, the provider elicits the current knowledge of the client about recovery. e provider announces that she would like to share some infor- mation instead of jumping into providing it. Finally, the provider elicits the client’s response to the information.

CHAPTER SUMMARY

slow progress, slips, and relapses, and unrealistic expectations are challenges that are o en encountered when clients engage in behavior change. Clients change at di ering paces and there are various reasons for why client progress may slow. Conceptualizing clients’ slow progress and related behaviors in an MI-consistent fashion—as a natural part of the change process, recognizing that motivation to change can vary over time—will likely reduce your frustration with these challenges. Many of the MI-consistent strategies we proposed can help you and your clients step back, evaluate, and better understand what has changed or what needs to change to help clients return to a level of motivation that facilitates change. our goal is that reading this chapter you will identify how you can utilize some of the MI-consistent strategies discussed in this chapter to help you match clients in their change process, help them better explore the slow progress, and help them to become more ready to change. Table 5.1 summarizes the clinical challenges and suggested MI strategies.

Table 5.1. summary of Motivational Interviewing strategies for Clinical Challenges with loss of Momentum

Clinical Challenge

Suggested MI Strategies

slow progress:

Completing treatment tasks, assignments, and goals at a pace that is inconsistent with expressed intention to change.

evocative questions: Ask questions to assess how clients perceive their progress or to identify changes that are a ecting progress.

Assessing importance and con dence: Ask scaling questions to assess if the importance of change or con dence to change has been altered.

Revising the change plan: step back and review the change plan to assess if it is working. Does it relate to the client’s goals?

emphasizing personal control: highlight the aspects of clients’ lives that are within their control when they perceive loss of control.

lapse and relapse:

Returning, either temporarily or longer term, to a problem behavior a er a period of maintained change.

Provide information: seek permission and give objective, clear and explicit information about the nature of slips and relapse and how they relate to the change process.

Reassess importance and con dence: elicit how the lapse/ relapse has a ected importance of and con dence to change.

looking back: Review recent change e orts to identify how the change was achieved and maintained. Discuss how clients can use this information.

Decisional balance: Ask about the pros and cons of continuing the problem behavior or re-engaging in changing.

eliciting and a rming strengths: Identify positive behaviors and strengths of client before the lapse/relapse.

Reframing: Re-conceptualize lapses or relapses as learning opportunities versus failure to change.

overly ambitious expectations:

expecting outcomes from the change process that are highly unlikely

or impossible to achieve.

Asking permission to share a concern: express your concern, with permission, about how clients’ expectations impact their change e orts.

evocative questions: elicit clients’ expertise on previous change attempts in comparison to their expectations.

elicit-provide-elicit: elicit clients’ knowledge about their expectations for change, provide objective information, and evoke client’s interpretation and reaction to the information.

6

Psychiatric Symptoms and Disorders

e National Alliance for the Mentally Ill (2013) de nes mental illnesses as “medical illnesses that can disrupt a person’s thinking, feeling, mood, abil- ity to relate to others, and daily functioning” (p. 3). Mental illnesses are also commonly referred to as mental disorders (American Psychiatric Association, 2013), neuropsychiatric disorders (World health organization, 2008), and psychiatric disorders (Kessler et al., 1994). Regardless of the terms used to refer to them, mental disorders are very common. In fact, according to the World health organization (2008) one third of the total years lost to disability worldwide are the result of mental disorders, such as depression, schizophre- nia, and alcohol use disorders. e National Comorbidity survey Replication, a large, nationally representative, epidemiological survey of mental disor- ders in the United states, found that in any given year just over one fourth of Americans ages 18 and older su er from a diagnosable mental illness (Kessler, Chiu, Demler, & Walters, 2005). us, even providers who do not treat men- tal disorders very likely provide services to individuals who are experiencing symptoms of a mental disorder. e current chapter provides guidance on MI-consistent strategies that can be utilized to address some common clinical challenges that arise when working with clients who are experiencing symp- toms of depression; certain anxiety, trauma-related, and obsessive compulsive disorders; or psychotic disorders.

e goal of the current chapter is not simply to provide guidance on how to use MI to enhance treatment for these disorders. Although mental health pro- fessionals using this book will nd several of the strategies described helpful for that purpose. Instead, this chapter is written with both the mental health professional and non–mental health professional in mind. As such, each section includes non-technical, descriptive information about the disorders and symp- toms of focus. e clinical challenges associated with each group of disorders are challenges that might be encountered in almost any setting where MI might be employed, from probation to health care to substance abuse treatment. similarly, the vast majority of MI-consistent strategies recommended could be employed

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just as easily in helping a client with a mental disorder engage in smoking cessa- tion or ful llment of probation requirements as in helping the client engage in treatment for the mental disorder.

CLINICAL CHALLENGE 1: DEPRESSION

Description

Major depressive disorder and other depressive disorders are characterized by various symptoms and associated features. In our own clinical practice of MI and that of others we have supervised, we have found the following features of depression can introduce particular challenges to the practice of MI: hope- lessness, feelings of worthlessness or guilt, di culty concentrating, and lack of interest in activities. Although everyone may experience hopelessness, guilt, di culty concentrating, or lack of interest in activities from time to time, it is important to note that these experiences are more intense and impairing in the context of a depressive disorder (American Psychiatric Association, 2013). In our work as psychologists, we sometimes talk with the families and loved ones of those who are experiencing a depressive disorder. In many cases it seems dif- cult for these concerned loved ones to understand how di erent the experience of guilt, for example, can be for an individual in the midst of a major depressive episode, than it is for someone without depression. is can make it di cult for these concerned others to understand “why she doesn’t just apologize and make amends—that worked for me.” us, in working with individuals who may be experiencing depression, we believe it is vitally important for providers to main- tain an MI spirit. To seek to understand how a particular client is experiencing hopelessness, guilt, di culty concentrating, or lack of interest, and not assume that the experience is like the provider’s experience or other clients’ experiences.

ese features of depression will likely necessitate adaptations to MI regard- less of whether you are a mental health provider or a provider of another type. For example, a client who feels hopeless about the future may have as much dif- culty discussing the steps she must take to satisfy probation requirements with her probation o cer as she does collaborating on a treatment plan for depression with her psychiatrist. In this section we seek to describe the signs and symptoms of depression that may impact a client’s ability to respond to MI, and the MI strategies that we have found most helpful in addressing these di culties. We try to provide this information in a manner that is relevant to mental health provid- ers and also accessible to providers who have no background in mental health.

Hopelessness

hopelessness generally refers to a negative perspective on the future—a lack of optimism (Beck & steer, 1988). Individuals who feel hopeless generally feel

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that there is something or several things about their lives that are undesirable or untenable, and that these things are unlikely to change. It is o en di cult for individuals who feel hopeless to even imagine how life might be better or di erent. ese individuals may thus have di culty engaging in MI-consistent tasks such as envisioning (e.g., “ If you were successful in making these changes, what would your life look like in ve years?”) and planning (e.g., “What is the rst step toward getting better control of your diet?”), which require this sort of imagining. Indications that a client you are working with may be experiencing hopelessness are presented in the quick reference.

Quick Reference
Client Utterances Expressing Hopelessness

I don’t know why I even bother, nothing ever works out.
Until my wife decides she is willing to quit, it’s not like I can do this anyway.

example: Hopelessness. Mario is a 36-year-old, divorced father of three who enters a tobacco cessation clinic at the urging of his primary care physi- cian. When asked about his con dence in his ability to quit smoking, Mario laments that he’s been a smoker for 20 years and he’s not sure why his doctor thinks he can quit now. He also reports that this isn’t a great time for him to try to quit, because smoking is the only thing that makes him feel good.

Proposed Strategy 1: Hypothetical Questions

Because hopelessness can interfere with a client’s ability to view change as pos- sible, it might be di cult for a client who is feeling hopeless to respond to direct questions about how they imagine life will be a er they make a change. e righting re ex (as described in chapter 2) can tempt a provider to try to convince a client that change is possible, but this can result in increased verbalizations of hopelessness (i.e., the client trying to convince the provider that change is not possible). Using MI-consistent hypothetical questions (Miller & Rollnick, 2013), a provider can help a client “work around” their hopelessness to begin imagining a life that might di erent and how they might achieve that change, without forc- ing them to relinquish their hopelessness before they feel ready or able to do so.

Example: MI-Consistent/Inconsistent Hypothetical Questions

e following examples illustrate common types of hypothetical questions:

Client statement: “It doesn’t matter what I try, I’ ll never be able to stop smoking.”

MI-Inconsistent: “I don’t buy that. If you try a little harder, I’m sure you can imagine what it might be like if you quit smoking.”

 

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is utterance is MI-inconsistent because the provider directly confronts the client about his hopelessness, accusing him of being dishonest and not putting forth enough e ort in an attempt to push him to envision the future.

somewhat MI-Consistent: “You sound really discouraged. Would a prescrip- tion for smoking cessation aids make you feel more con dent?”

is response is somewhat MI-consistent. e provider o ers an empathic re ection and then attempts to get the client to envision the possibility that he might someday be able to get smoking. however, to so, the provider uses a closed question, which invites only a brief response. e question also proposes the provider’s solution rather than eliciting reasons or means for change from the client.

MI-Consistent: “Right now it is hard to imagine that you will ever be success- ful in your smoking cessation e orts. If you were to imagine that somehow it was possible for you to quit, what might be di erent or better in your life?”

is provider utterance is MI-consistent, because it begins with a re ection of the client’s hopelessness rather than a challenge of it. e provider then gently, and with respect for the client’s hopelessness, invites him to hypo- thetically consider what his life will be like if he is successful. is is a very basic use of the hypothetical question.

MI-Consistent: “It’s been really discouraging to try so many times and not have lasting success, and it’s even hard to envision a future without smoking. Just for the sake of exploring this, imagine if you will, Mario, that I had a magic cure that would make it possible for you to stop smoking for good. How would your life be better or di erent?”

is provider utterance is MI-consistent because it begins with a support- ive statement and a re ection of the client’s hopelessness. e provider then uses a type of hypothetical question that is sometimes referred to as a “miracle question” to invite the client to consider the possibility of change without immediately letting go of his hopelessness. e utterance is also MI-consistent, because the provider gives the client permission not to imagine the miracle cure.

MI-Consistent: “You don’t feel very con dent about your ability to stop smoking. What would it take to make you more con dent that it might be possible?”

is provider utterance is MI-consistent, because it again begins with a re ection. e provider then goes on to invite the client to hypothetically consider things that might favorably alter his perspective on the possibility of change. is type of hypothetical question can be used as a follow-up to a con dence ruler (“on a scale of 0 to 10, how con dent are you about your ability to quit smoking?”—see chapter 3) for client’s who express limited con dence in their ability to change.

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Proposed Strategy 2: Planning

As the previous examples illustrate, clients who feel hopeless may have di culty imagining the possibility of change. ere is also evidence that individuals who experience depressive disorders may have di culty engaging in problem solv- ing (D’Zurilla & Nezu, 2007). is di culty in identifying and implementing solutions to important life problems may contribute to the sense of hopelessness that seems to sometimes make it di cult for individuals who are experiencing depression to fully engage in an MI session. Problem solving requires a series of steps that are not dissimilar to the planning process in a motivational interview, including setting goals, generating solutions, and making decisions (D’Zurilla & golfriend, 1971). us, engaging clients in an MI-consistent planning process (see chapter 3) during which clients set goals and work collaboratively with the provider to identify a workable strategy to achieve those goals may help foster client belief that change is possible.

Example: MI-Consistent/Inconsistent Planning

e following examples illustrate how an MI provider might use planning to help a client overcome hopelessness:

Client statement: “It doesn’t matter what I try, I’ll never be able to stop smoking.”

MI-Inconsistent: “ ere is a new medication that was just FDA approved for smoking cessation. I’m going to write you a prescription. Many of our clients report that smoking cessation is much easier on this medication than without it.”

Although the provider acknowledges the di culty that the client has had with prior smoking cessation attempts and attempts to instill hope by pre- scribing a new drug, this provider utterance is MI-inconsistent because it is non-collaborative. e provider assumes the expert role and seeks to make the client a passive recipient of medical advice.

somewhat MI-Inconsistent: “I have a change plan worksheet we can ll out together to create a strategy for change. How does that sound?”

is response is somewhat MI-consistent. e provider suggests that a change plan worksheet be lled out and asks the client for feedback on that idea. In another context this response might be very collaborative. however, given the client’s prior expression of hopelessness, the abrupt manner in which this idea was presented conveys both a lack of collaboration and a lack of empathy (i.e., in response to the client’s statement that he can’t change, the provider essentially says “let’s talk about how you can change”).

MI-Consistent: “Right now it is hard to imagine that you will ever be success- ful in your smoking cessation e orts. is may or may not be helpful for you, but some clients have found that talking very speci cally about their goals and the di erent strategies they might use to achieve their goals helps them

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to feel a bit more hopeful about the possibility of success. I’m wondering if we could do that now.”

is provider utterance is MI-consistent, because it begins with a re ec- tion of the client’s hopelessness rather than a challenge of it. e provider then provides Mario with information about planning as a potential strat- egy to increase his hopefulness. In doing so, the provider supports Mario’s autonomy and the collaborative nature of the interaction by explaining that Mario may or may not nd it helpful (see full description of planning in chapter 3 and sample change plan worksheets found in Table 6.4 and in chapter 4).

Feelings of Worthlessness or Guilt

Feelings of worthlessness or guilt are another common feature of depression that may in uence how clients experience certain MI-consistent strategies. Individuals who feel worthless or experience excessive guilt may devote great amounts of time to thinking about mistakes they have made, de cits they per- ceive themselves to have, ways in which they have disappointed others, and so on. us, when asked by a provider during an MI-consistent eliciting process, “What are the reasons you want to make this change?” they may identify numer- ous well-articulated, thoroughly elaborated reasons why the change is necessary. In our experience as MI supervisors, we have found that it is tempting for pro- viders to view these utterances as evidence that the MI is going very well and that the client is very engaged. however, closer examination of the content of these utterances from clients who are experiencing depression o en reveals that the provider is not helping the client identify reasons for change. Rather, the provider is inviting clients to give voice to and even expound upon a destructive, self-deprecating inner monologue that occupies much of their thinking. If you think of the depressive rumination as “beating oneself up” you could almost think of using MI eliciting to encourage the client to expound upon destructive self-evaluations as “giving the client a bigger paddle with which to beat himself.” Indications that your client may be experiencing feelings of worthlessness or excessive guilt include frequent or extreme self-deprecating comments: “What is wrong with me?” “I’m not very smart,” “I should know better,” “I don’t under- stand why anyone would want to be around me” and/or frequent or extreme confessions: “I shouldn’t have been so nasty to her,” “I screwed up again,” “I’m always doing stupid stu like that.”

example: As Mario, the 36-year-old, divorced father of three continues his initial consultation for smoking cessation, the provider asks him why he is considering quitting smoking. Mario looks at the oor and in a very low voice tells the provider that he is a terrible example for his kids and he just really

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needs to get his life together or maybe they’d be better o without him. e provider, using MI-consistent strategies, says, “Tell me more about why you think smoking is a bad example for your kids.” Mario responds by explain- ing that he never does anything right and that he is sure his kids have no respect for him at all, because not only does he smoke, but he also lost his job, destroyed his marriage, and is getting fat besides.

Proposed Strategy 3: Envisioning

As noted, clients who feel worthless or experience excessive guilt may respond to provider questions about problems or negative consequences they have expe- rienced with self-deprecating comments that may actually hinder rather than facilitate change e orts. Remember, it is important not only for clients to view change as necessary, but also as possible. given that a rmations from the pro- vider or questions from the provider that invite the client to describe past suc- cesses or strengths may enhance self-e cacy (i.e., the client’s belief in his or her own ability to complete tasks and reach goals) (Bandura, 1977) it is reasonable to suspect that questions from the provider that cause the client to describe past failures or weaknesses may diminish self-e cacy. Because clients who feel worthless or experience excessive guilt may view their past as littered with mis- takes, shortcomings, regrets, and few accomplishments or achievements, it may be useful for a provider to instead invite the client to focus on the future. In other words, what is possible, not what has already transpired. As noted in the preceding section of this chapter, feelings of hopelessness can make envisioning di cult and may require the use of hypotheticals.

Example: MI-Consistent/Inconsistent Envisioning

e following examples illustrate how a provider might use envisioning (Miller & Rollnick, 2013) to work around worthlessness or guilt.

Client statement: “I can’t believe I smoked at home with my kids. I’m such a bad father. If they get asthma or something, I know it will be all my fault. No wonder my wife le me. What kind of piece of garbage father would smoke with his kids around? It was stupid and irresponsible and I can’t undo it.”

MI-Inconsistent: “You’ve got to let that stu go and focus on what you can do now.”

Although the provider seems to be trying to comfort the client and is com- ing from a position of compassion, the statement is MI-inconsistent because the provider is in essence ordering the client to stop having those thoughts. at is not collaborative and does not support the client’s autonomy.

somewhat MI-Consistent: “ e important thing is that you’re here now. Let’s talk about how to approach smoking cessation this time.”

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is response is somewhat MI-consistent. e provider seeks to a rm the client and shi the focus to smoking cessation. however, by failing to acknowledge in any meaningful way what the client has just said, the pro- vider conveys that he or she is not interested in the client’s perspective on anything other than how smoking cessation can be accomplished.

MI-Consistent: “I’m hearing loud and clear that you have a lot of regrets about smoking for so long and that a big part of that relates to how important it is for you to be a good father. at’s really noble. Tell me how your rela- tionship with your kids might be di erent if you were successful in quitting smoking.”

is provider utterance is MI-consistent, because it begins with a re ection of the client’s thoughts and feelings. e provider then goes on to a rm the client for the importance he places on being a good father. Finally the pro- vider uses an open question to try to elicit from the client change talk that is hopeful, rather than self-deprecating.

Proposed Strategy 4: Af rming

Clients who feel worthless or experience excessive guilt may have di culty rec- ognizing or acknowledging their strengths and successes. is can undermine their con dence in their ability to change. In working with these clients it can be especially important for a provider to be attuned to anything the client might be saying that could hint at positive qualities, strengths, or past successes. o en a rmations with clients who feel worthless or experience excessive guilt will involve reframing something the clients has presented as a weakness or failure in a more objective and positive way.

Example: MI-Consistent/Inconsistent A rming

e following examples illustrate how a provider might use a rmations to overcome worthlessness or guilt.

Client statement: “I can’t believe I smoked at home with my kids. I’m such a bad father. If they get asthma or something, I know it will be all my fault. No wonder my wife le me. What kind of piece of garbage father would smoke with his kids around? It was stupid and irresponsible and I can’t undo it.”

MI-Inconsistent: “Yes. Secondhand smoke is really bad for kids. Until you get a handle on this, I think your ex-wife is doing the right thing by not letting the kids be around you.”

is statement is MI-inconsistent because the provider directly confronts the client about his smoking. is statement also demonstrates a lack of collaboration and compassion because the provider expresses more concern for the client’s ex-wife and children than for the client.

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somewhat MI-Consistent: “ e important thing is that you are here now.”

is response is somewhat MI-consistent. Although the provider seeks to a rm the client, the selected phrasing might be perceived as somewhat unempathic or dismissive by the client. It is obvious from the client’s utter- ance that the important thing to him is the impact his smoking has had on his family.

MI-Consistent: “ e way you take your role and responsibility as a father so seriously is really impressive. I know you haven’t been as successful as you’d like with previous smoking cessation, but it is hard to imagine anyone taking it more seriously than you do.”

is provider utterance is MI-consistent because it a rms the positive qualities and values that likely underlie Mario’s self-deprecating statements. ese a rmations may help Mario view himself less as a “piece of garbage” and more as a awed human being who is still capable of change.

MI-Consistent: “You are really dedicated to being a good father. Tell me about some other qualities such as your dedication to your family that might help you quit smoking.”

is provider response is MI-consistent because it a rms a strength of the client. e statement also explicitly encourages the client to identify other strengths he may not be recognizing at this time.

Dif culty Concentrating

Concentration generally refers to the ability to focus one’s attention or thoughts on a particular object or activity, and not attending to distractions (lezak, 1995). Di culty concentrating o en interferes with an individual’s ability to learn new information. For example, as you’ve been reading this book, there have probably been one or more occasions when your thoughts wandered to another topic (e.g., “I have to remember to mail that letter tomorrow.”) or you noticed something new in your environment (e.g., “ e sky is getting dark, a storm must be rolling in.”). As you noticed your distraction and directed your thoughts back to the text, you may have realized you had no idea what you had read in the past ve minutes. Di culty concentrating can also impair an individual’s ability to respond appropriately and e ectively in social situations. For example, multiple times while writing this book, I (Js) received a call from my husband. Not wanting to lose my train of thought before getting it down on paper, I tried to multi-task—to talk to my husband and nish typing my ideas for this book. Needless to say, my husband noticed (and commented on it!). ere were inappropriately long pauses in my speaking, I sometimes provided incoherent responses to his queries, and occasionally had to ask him to repeat what he had just said. Although not unique to depression, individuals who su er

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from depressive disorders o en report di culty concentrating. Individuals who experience excessive worry (generalized anxiety disorder), posttraumatic stress disorder, attention de cit hyperactivity disorder and certain other psychiatric conditions may also experience di culty concentrating. Indications that your client may be experiencing di culty concentrating are presented in the quick reference box.

Quick Reference
Indicators of Concentration Di culties in Clients

Frequent requests for repetition of information or questions
Inability to respond to queries about content previously discussed in the session e appearance of daydreaming
losing train of thought

example: When Mario, the 36-year-old, divorced father of three pro- ceeded with his intake at the smoking cessation clinic, the provider began to ask him a question about his history of smoking. Mario began telling the provider about how he started smoking at the age of 16 by stealing his father’s cigarettes and buying them from a local convenience store that didn’t seem to care about selling to minors. en Mario paused for a few moments, got a confused look on his face, and asked, “I’m sorry, what was the question?”

Proposed Strategy 5: Summarizing

As outlined in chapter 2, the basic skills of MI are open questions, a rma- tions, re ections, and summaries (oARs). Rosengren (2009) outlines three di erent primary purposes that MI-consistent summaries can serve during a provider-client interaction, including listing important things the client has said (e.g., change talk), linking something a client has just said to something said previously, or helping to transition the conversation to a new topic or new MI process (e.g., transitioning from evoking to planning). It has been our experience that summaries can also be used as a tool to enable a client who seems to have di culty concentrating to better participate in an interaction. For clients who have di culty concentrating, listing summaries may not only reinforce previ- ously discussed material, but they may enable the client to grasp content of the session that was missed due to di culty concentrating. linking and transition summaries may help the client draw conclusions or make connections that he or she was unable to make during the session because he or she was distracted by other thoughts.

 

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Example: MI-Consistent/Inconsistent Summaries

e following examples illustrate how a provider might use summaries to help a client who has di culty concentrating participate more fully in an interaction.

Client statement: “I’m sorry. What was the question?”
MI-Inconsistent: “Mario, you really need to focus on what we’re doing here.

I asked you to tell me about your history with smoking.”

is statement is MI-inconsistent because the provider not only repeats the question, but also attempts to shame the client about his lack of concentra- tion. e provider talks down to the client in a paternalistic fashion, which could spring the expert trap.

MI-Inconsistent: “Don’t worry about it. Let’s just go on to the next question.”

Although this provider statement indicates that the provider is sympathetic to the client’s di culty concentrating, it is not collaborative. e client requested that the question be repeated and the provider in essence over- rules this request and takes full control of the direction of the session.

somewhat MI-Consistent: “Tell me about your history with smoking.”

is provider statement is somewhat MI-consistent. e client asked a ques- tion and the provider responded. In MI, answering a question is considered a form of giving information. however, given the circumstances, the pro- vider’s perfunctory response shows a potential lack of empathic attunement to the di culties Mario is having with the interview.

MI-Consistent: “I had asked you about your history of smoking and you were telling me about how you started at the age of 16 with smoking your father’s cigarettes and purchasing them from a convenience store that didn’t check your ID.”

is provider utterance is an MI-consistent summary. It is a collaborative response to the client’s question that is intended to help the client fully engage in the interaction.

Proposed Strategy 6: Using MI-Consistent Handouts

Although written change plans, decisional balance worksheets, readiness rul- ers, and informational handouts are considered optional components of an MI-consistent provider-client interaction, we have found that many clients, regardless of their ability to concentrate, appreciate receiving these materials. ese materials can help clients recall and refer back to key elements of their interaction with the provider. For example, several clients who receive motiva- tional interviews from psychology interns through an MI practicum I (Js) super- vise at a community residential substance abuse treatment facility report posting their change plan worksheet beside their beds. ey report that they like to be

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reminded daily of their goals and the steps they plan to take in achieving those goals. e fact that these documents are so meaningful to these clients is very telling; the motivational interview they receive represents just one hour out of 100 or more hours of treatment they receive. similarly, the change plan work- sheet represents just one of dozens of treatment-related papers they complete during their six-week stay at the facility. We have also found that these types of aids can be particularly helpful for clients who have di culty concentrating and thus may be less able to recall key elements of the session than typical clients.

Example: MI-Consistent/Inconsistent Handouts

e following examples illustrate the types of MI-consistent handouts that might be provided to a client to help him or her overcome de cits in concentration.

MI-Inconsistent

• Any materials that judge or label a client’s situation, condition, or

circumstances in a way that is inconsistent with how the client labels his or her own situation, condition, or circumstances (e.g., providing a handout that describes “signs of Alcoholism” to a client who insists that he may drink a lot but is not an alcoholic.)

• Any materials that describe a treatment plan that was created without

the client’s collaboration or give advice with the client’s permission (e.g., handing a client a “dietary guidelines” handout and telling him or her to follow it rather than asking if he or she would like the handout, or giving the client permission to use it or not by saying, “You might nd this helpful.”).

Somewhat MI-Consistent

• Handouts that provide information in an objective, non-labeling fashion

that is consistent with the client’s self-perception, but are not requested by the client or o ered to the client with permission to disregard them if desired.

MI-Consistent

• Session/consultation/meeting agendas can be negotiated and presented

in written or verbal form. A er the agenda has been negotiated between a provider and client, placing a written version of the agenda between the client and provider may help a client who has di culty concentrating stay more focused during the interaction. samples of written agenda forms can be found in Mason and Butler (2010).

• Readiness rulers are used as both an assessment tool and a technique

for eliciting change talk (Rollnick, Miller, & Butler, 2008). ese rulers can be administered verbally or in written form. For clients who have

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di culty concentrating or might otherwise bene t from having a record of this exercise, a written form that includes both their rating and a written description of the reasons for the rating might be used (Table 6.1).

• Decisional balance (Janis & Mann, 1977), which used to be considered

a strategy for evoking change talk in MI (Miller & Rollnick, 2002) and is now considered a neutral strategy for assisting a client in determining whether or not they desire to change (Miller & Rollnick, 2013), involves having a client articulate the reasons to change and the reasons to stay the same. Decisional balance exercises are o en completed in written form and provide the client with a useful summary of all the factors he or she considered in deciding to change (or not change). A sample form for completing a decisional balance is included in Table 6.2. Note that
if you decide to use this technique no form is needed—we o en prefer to draw a large “+” in the middle of a blank sheet of paper and place appropriate headings in each quadrant.

• During an MI-consistent planning process, the client and provider will

o en collaboratively complete a change plan worksheet that is intended to remind the client of key aspects of his or her change plan. elements you may wish to include on a change plan worksheet are the change the client wants to make, the reasons he or she wants to make the change, the steps he or she will take or the strategies he or she will use to
change, what supports he or she will need to change (people, treatment programs, books, etc.), and how he or she will evaluate the plan and make changes if it is not helping the client achieve desired results (Miller & Rollnick, 2002). samples of change plan worksheets are presented in chapters 4 and 7 and Table 6.4.

Lack of Interest in Activities

lack of interest in activities is another feature of depression that can present unique clinical challenges. of particular import in depressive disorders is a lack of interest in activities that used to be enjoyed or an inability to take pleasure in activities that were previously enjoyed. Whereas many individuals who are con- fronted with di cult behavioral changes such as initiating an exercise program, starting a diet, quitting smoking, or searching for a job may nd it di cult to be interested in or intrinsically motivated to engage in activities that are not imme- diately rewarding or pleasurable (but do promote progress toward the goal), most individuals will have no di culty engaging in activities that are immedi- ately rewarding or pleasurable. For example, I (Js) sometimes found it di cult to get myself interested in sitting down to work on this book, even though complet- ing the book was a goal of mine and was highly valued. In contrast, I rarely if ever nd it di cult to get myself interested in eating fries from my favorite fast food restaurant, reading a trashy novel, or getting a massage or pedicure. ese

Table6.1. sampleReadinessRulerhandout

My goal Is:

on a scale of 0 to 10, with 0 being not at all important and 10 being very important, I rate the importance of achieving this goal as (circle one):

0 1 2 3 4 5 6 7 8 9 10

My rating is a and not a lower number for the following reasons (list reasons):

1. 2. 3. 4. 5.

on a scale of 0 to 10, with 0 being not at all con dent and 10 being very con dent, I rate my con dence in my ability to achieve this goal as (circle one):

0 1 2 3 4 5 6 7 8 9 10

My rating is a and not a lower number for the following reasons (list reasons):

1. 2. 3. 4. 5.

138 MoTIvATIoNAl INTeRvIeWINg FoR ClINICAl ChAlleNges Table 6.2. sample Decisional Balance handout

Reasons to Quit Smoking

is quadrant generally includes negative consequences the individual has experienced as a result of the target behavior (i.e., smoking)

• “My doctor is concerned about my
health.”

• “My kids hate the smell.”

• “My workplace is going smoke free.”

• “Cigarettes are expensive.”

Reasons to Continue Smoking

is quadrant generally includes positive consequences the individual has experienced as a result of the target behavior (i.e., smoking)

• “Smoking helps me relax.”

• “I enjoy smoking.”

Reasons not to Quit Smoking

is quadrant generally includes negative consequences the individual anticipates experiencing as a result of changing the target behavior (i.e., smoking)

• “Now is not a good time—I’m under

a lot of stress.”

Reasons not to Continue Smoking

is quadrant generally includes negative consequences the individual anticipates experiencing as a result of changing the target behavior (i.e., smoking)

• “I want to live to see my children get
married.”

• “I’ve wanted to quit for over 10 years.”

• “With all the money I’d save every
year, I could take my kids to Disney World.”

behaviors are not particularly consistent with any important long-term life goals, but I enjoy them. In contrast, individuals who are experiencing a depres- sive episode may experience di culty getting interested in or taking pleasure from activities that normally bring pleasure. For example, an individual who is experiencing a depressive episode may have no interest in accompanying me to a fast food restaurant for fries and a milkshake, even though he or she normally loves fries even more than I do. Instead he or she might decide, “I just don’t feel like it.” Indications that your client may be experiencing lack of interest in activi- ties may include reports of decreased engagement in activities, an inability to generate ideas or options when asked what they would like to do, or direct state- ments such as “I just don’t seem to get excited about anything anymore.”

example: As Mario, the 36-year-old, divorced father of three works col- laboratively with his provider to develop a plan for tobacco cessation, the provider suggests that Mario identify ways to reward himself for meeting his daily smoking goals. A er a lengthy pause, the provider explains that many

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individuals nd that giving themselves a treat such as 30 minutes playing video games or using a social networking site, eating a special food treat such as a miniature candy bar or serving of chips, or getting praise from a loved one for their successful e orts each day can help them stay on track. Mario hesi- tates and ponders the provider’s suggestions and then explains that he cannot think of anything that he really enjoys right now or would nd rewarding.

Although the provider is attempting to be supportive and nd activities that may reinforce the client’s successes with smoking cessation, the discussion is likely to be circular. e more the provider succumbs to the righting re ex and suggests rewards, the more insistent Mario may become in his arguments that he simply cannot think of anything. For someone who has depression, you may have to focus on times when the client was not experiencing depression to iden- tify rewarding activities, things clients like, or strengths.

Proposed Strategy 7: Looking Back

Although clients experiencing depression may not currently be able to identify activities they nd pleasurable, attempting to elicit what things were like and what activities they enjoyed when they were not feeling depressed can help. us, the MI-consistent strategy of looking back may help (Miller & Rollnick, 2013).

Example: MI-Consistent/Inconsistent Looking Back

e following examples illustrate how a provider might use looking back as a strategy to address a client’s current lack of interest.

Client statement: “I cannot think of anything that I enjoy right now.” MI-Inconsistent: “Mario, we all have something that we like to do. What is

it for you?”

is response is MI-inconsistent because the provider actually invalidates the client’s statement and minimizes the struggle he is having. e provider falls victim to the expert trap and the response is likely to elicit sustain talk versus generating any potential solutions.

somewhat MI-Consistent: “What did you enjoy before you got divorced?”

is response is somewhat MI-consistent. e provider asks an open ques- tion to help the client identify things that he used to enjoy. however, the pro- vider asks the question without rst re ecting the client’s statement. us there is a missed opportunity to express empathy. is failure to acknowl- edge the client’s di culty before asking the question may also cause the client to experience this continued questioning as non-collaborative.

MI-Consistent: “Mario, I certainly can see that it is a struggle for you to nd things you currently enjoy and that it is frustrating for you. I wonder if it would be helpful for us to look back to a time before your divorce, when

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you were feeling much better and doing more things. What were some of the enjoyable things for you at that time?”

is provider utterance is MI-consistent. e provider begins by validat- ing the client’s situation and feelings about not enjoying things. Next, the provider acknowledges that there was a prior time when the client was not depressed and asked the client to look back at that time for ideas.

CLINICAL CHALLENGE 2: ANXIETY, TRAUMA-RELATED, AND OBSESSIVE COMPULSIVE DISORDERS

Description

According to the Diagnostic and Statistical Manual of Mental Disorders, Fi h edition (DsM-5), “Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances” (pp. 189, American Psychiatric Association, 2013). A common behavioral disturbance shared by many anxiety disorders is avoidance. is feature is also shared by some disorders that were previously classi ed as anxiety disorders in the DsM including obsessive-compulsive disorder and posttraumatic stress disorder (American Psychiatric Association, 2000, 2013). Avoidance refers to e orts by an individual to avoid people, situations, stimuli, thoughts, or feelings because they arouse unpleasant emotions, particularly fear or anxiety. For example an individual who is experiencing a speci c phobia of snakes may avoid looking at pictures of snakes; going to zoos, natural science museums, or pet stores where snakes might be encountered; and going outside at night or without wearing boots during the day in case snakes might be encountered.

Avoidance is of concern to those who treat anxiety disorders, because there is evidence that although avoidance may reduce anxiety in the short term, it actu- ally serves to maintain and even increase anxiety over time (e.g., Clark, 1999). For example, an individual with a snake phobia who runs back into the house and locks the door when a neighbor calls to tell him or her that she found a harmless garden snake in her yard that morning might immediately experience a decrease in anxiety upon doing so. however, over time he or she might come to fear and avoid the back patio and backyard entirely, and may eventually refuse to leave the house unless wearing protective leather boots.

Avoidance presents clinical challenges, because many of the most e ective psychotherapies for disorders such as speci c phobia, obsessive-compulsive dis- order, and posttraumatic stress disorder include exposure-based interventions (Doyle & Pollack, 2003). exposure-based interventions involve having an indi- vidual who is avoiding situations, people, stimuli, thoughts, or feelings because they elicit a strong anxiety or fear reaction to intentionally come into contact with those situations, people, stimuli, thoughts, or feelings and tolerate the

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intense anxiety or fear (hofmann & smits, 2008) Whether you have worked with individuals who have anxiety, trauma-related, or obsessive-compulsive disor- ders; watched reality television programs that depict exposure based treatment; had friends or family members who su ered from such disorders; experienced an anxiety or related disorder yourself; or have no direct experience with anxiety or related disorders; you can probably imagine that nding the motivation to complete exposure-based treatment is a challenge. We admire the courage of the many individuals we have treated with exposure-based treatments over the years and have found the use of many MI strategies helpful in assisting these individu- als to nd the motivation and courage to reclaim their lives through completion of exposure-based treatment.

example. Jamal is a 32-year-old man who has been diagnosed with posttrau- matic stress disorder subsequent to a single car motor vehicle accident during which he was seriously injured and the driver of the vehicle was killed. Since the accident, Jamal has been unable to drive on the freeway, a er dark, or in unfamiliar neighborhoods. He also becomes incredibly upset when he sees a black sedan (the car involved in the accident was a black sedan) or hears jazz music (he and the driver were listening to jazz on the radio at the time of the accident). During their second visit, a social worker provides Jamal with information about his diagnosis and exposure-based treatment. Jamal expresses that the symptoms of PTSD have ruined his life and he is willing to do whatever it takes to get past this. However, shortly a er the exposure-based interventions begin, Jamal states that he is not certain he wants to continue with treatment and tries to convince the social worker that having PTSD is really not that bad.

As illustrated in this example, avoidance can interfere with a client’s ability to complete exposure-based treatment, even if he or she does not express any initial hesitation or concern about the treatment. In our own work, we nd that not all clients express doubt about their ability to tolerate exposure-based treatment. In fact a signi cant minority express unrealistic optimism about their ability to tol- erate exposure-based treatment without any di culty. With the help of a caring, compassionate, and competent professional, there are only a handful of situa- tions that would be considered contraindicated for exposure-based interventions (e.g., vanMinnen, harned, Zoellner, & Mills, 2012). Nonetheless, the very nature of anxiety, trauma-related, and obsessive-compulsive disorders, as well as exposure-based treatment almost ensures that an expectation of no distress or avoidance is unrealistic for most clients. us we also outline MI-consistent strategies to help clients set realistic expectations for exposure-based treatment (see also chapter 5).

Avoidance related to anxiety can interfere with e ective provision of inter- ventions and services of all types, not simply those that involve exposure-based treatments (Westra, 2012). Individuals with social anxiety have intense fear or anxiety about one or more social situations that expose the individual to

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possible evaluation by others. is fear and anxiety stem from a belief they will act in some way that will be negatively evaluated by others in the feared social situations. As a result these situations are avoided or endured with intense fear and anxiety (American Psychiatric Association, 2013). For example, individ- uals with social anxiety may avoid making phone calls, coming to appoint- ments, speaking up in groups, or engaging actively in one-on-one meetings. is fear, anxiety, and avoidance may interfere with an individual’s ability to participate fully in almost any situation or setting in which MI might be uti- lized, from a meeting with a probation o cer, to an appointment with a fam- ily care provider, to a substance abuse treatment group. In our own clinical practice of MI and supervision of others’ MI practices, we have identi ed MI strategies that may be useful in working with individuals who avoid treatment because of social anxiety.

example. Sanjay is an 18-year-old male who su ers from social anxiety. He has been referred to the counselor at his school to discuss decreasing atten- dance and performance. Sanjay’s teachers report that he o en looks at his desk or ddles with his pen, never raises his hand to participate in class dis- cussions, and o en seems unprepared when called upon to answer a question or present information to the class. As the counselor talks to Sanjay about his problems at school she discovers that several of his classes require presenta- tions this year and that his political science instructor, a former law profes- sor, o en calls on students randomly and expects them to know the answer. Sanjay explains that his heart races whenever he thinks about the presenta- tions and political science class and he just knows he’s going to “mess up” in front of the class and all of the kids will think he’s stupid.

Proposed Strategy 1: Empathic Listening

We know from our work with community providers who do not specialize in mental health (and even sometimes those who do) that lack of engagement due to social anxiety is o en misattributed to lack of motivation or weakness. As you read these descriptions, you might have been thinking, “Who hasn’t felt their heart race when they stand up to speak before a crowd of people?” or “Who hasn’t shuddered a bit when they saw a particularly fearsome looking snake or spider?” As with depression, it is important to note that although everyone experiences fear or anxiety from time to time, the experiences are more intense and impair- ing in the context of an anxiety disorder (APA, 2013). us, it is very important to listen empathically and attempt to understand the clients’ experience of anxi- ety rather than assuming that your personal experience with anxiety makes you an expert on the client’s experience. is is true even if you have su ered from the same disorder the client is experiencing (see chapter 8 for additional infor- mation about the unique challenges that arise when working with clients who are similar to you).

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Example: MI-Consistent/Inconsistent Empathic Listening

e following examples illustrate how to use empathic listening to under- stand the role anxiety may play in a client’s lack of participation in an intervention:

Client statement: “I’m going to say something stupid and the other kids are going to laugh at me.”

MI-Inconsistent: “Everyone gets nervous sometimes Sanjay. You just need to have faith in yourself and speak out con dently.”

Although the provider seems to be trying to express warmth and compas- sion to the client, this provider utterance is nonetheless MI-inconsistent. Instead of demonstrating empathy by re ecting sanjay’s concerns, the provider instead provides information as an attempt to dismiss sanjay’s concerns. e provider then goes on to tell sanjay what to do, which is not collaborative and does not support sanjay’s autonomy.

somewhat MI-Consistent: “What do you think might make you feel less ner- vous about speaking up in class?”

is response is somewhat MI-consistent. e provider asks an open ques- tion that invites sanjay to share his perspectives. however, this question is asked before the provider has elicited enough information from sanjay to really understand what his experience of anxiety is like, and what his moti- vations to implement strategies to reduce anxiety might be.

MI-Consistent: “You are really worried that the other kids might think poorly of you if you speak up in class.”

is provider utterance is MI-consistent because the provider empathically re ects the client’s feelings and concerns without trying to minimize them or force him to adopt a new perspective.

MI-Consistent: “So if you felt more con dent that the other kids wouldn’t laugh at you, you’d be more willing to participate in class.”

is provider utterance is also MI-consistent and is also an empathic re ec- tion. is re ection is more complex than the previous example as the provider reframes the client’s concerns as a possible intervention target. A provider might choose this type of re ection to help the client begin to consider that change is possible.

Proposed Strategy 2: Assessment Feedback

In our work with individuals with anxiety disorders, obsessive-compulsive disorders, and trauma-related disorders, we have found that many clients ben- e t from provision of MI-consistent feedback from their diagnostic assessment (e.g., Miller, Zweben, DiClemente, & Rychtarik, 1992). An example comes from a recent clinical trial that included an MI-based intervention as a preparatory

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intervention for individuals who enrolled in a clinical trial for treatment of co-occurring alcohol use disorders and posttraumatic stress disorder (Co ey et al., 2013). In this study, we found that the rst participants who enrolled in the study had di culty articulating the potential bene ts of receiving treatment for posttraumatic stress disorder because they did not realize that the constellation of distressing and life-interfering symptoms they were experiencing could all be traced to their diagnosis of posttraumatic stress disorder. however, once pro- vided with objective information about the diagnosis, including feedback from their diagnostic evaluation, participants could readily articulate: (1) the ways in which the symptoms, distress, and impairment associated with posttraumatic stress disorder had negatively impacted their lives, and (2) the way their lives would be better, richer, and fuller if they were successful in treatment and no longer experienced the symptoms, distress, and impairment associated with the diagnosis.

Example: MI-Consistent/Inconsistent Assessment Feedback

e following examples with Jamal, the man described earlier who devel- oped posttraumatic stress disorder as a result of a motor vehicle accident, illustrate how a provider might use assessment feedback to help a client with an anxiety, trauma-related, or obsessive compulsive disorder develop su – cient motivation to participate in treatment and reduce their symptoms.

Client statement: “My life has been ruined ever since the car accident.” MI-Inconsistent: “If you want to regain your life, I recommend you partici-

pate in a treatment called exposure therapy.”

is response is MI-inconsistent because the provider gives advice without permission, which reduces collaboration and may also diminish the client’s sense of autonomy. e provider also fails to demonstrate empathy with Jamal’s obvious angst.

somewhat MI-Consistent: “You have a disorder called PTSD and that is why you’ve been struggling so much since the accident. You can do a treatment called exposure therapy that will help you get past it.”

is response is somewhat MI-consistent. e provider o ers Jamal objec- tive information about his condition. however, the provider does not ask permission before giving the information or elicit the client’s response to the information. e provider also jumps to planning (o ering a treatment approach) without eliciting Jamal’s motivation for treatment.

MI-Consistent: “Jamal, would it be okay with you if I shared some feedback from your assessment that might help you better understand why things have been so di cult for you since the car accident?”

is provider utterance is MI-consistent, because the provider asks permis- sion to give information, which supports the client’s autonomy, and also demonstrates both sympathy and empathy for the di culty the client has experienced as a result of the car accident that took the life of his friend.

Psychiatric symptoms and Disorders 145 Table 6.3. example of objective Written Feedback from a PTsD Assessment

Posttraumatic Stress Disorder Assessment Results

TRAUMATIC EVENTS IN YOUR LIFE

YOUR TRAUMA SYMPTOMS

Posttraumatic Stress Disorder (PTSD) Diagnosis yes no Avoidance symptoms

           

Re-experiencing symptom
Hyperarousal symptoms
Overall trauma symptom severity:
mild moderate

severe

very severe

 

Table 6.3 provides an example of what MI-consistent written feedback from a PTsD assessment might look like. is feedback is most helpful when pre- sented in the context of verbal or written interpretive information that will help clients make the most of the information (e.g., Miller et al., 1992).

Proposed Strategy 3: Evocation

For clients who present with anxiety, trauma-related, or obsessive-compulsive disorders for which an exposure-based treatment is recommended, using MI-consistent evocative questions to help them articulate their own reasons for change may be essential to helping them foster the motivation and strength to overcome their avoidance and pursue treatment (Westra, 2012). evocative ques- tions can most easily be accomplished a er clients have been provided with assessment feedback or other information that gives them a clear understanding of how the symptoms they have been experiencing are linked to their diagnosis.

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Example: MI-Consistent/Inconsistent Evocation

e following examples illustrate how a provider might use evocation to help a client develop su cient motivation to overcome avoidance and engage in treatment:

Client statement: “My life has been ruined ever since the car accident.”

MI-Inconsistent: “Well, I have good news Jamal. I can o er you a treatment that is very e ective for helping people move past traumatic events like car accidents.”

is provider utterance is MI-inconsistent, because the provider does not evoke the client’s desire, ability, reasons, need, or commitment for change. Instead the provider assumes that because the client reports that his life is ruined that his motivation is su cient and jumps directly to planning. e planning is MI-inconsistent because it is non-collaborative; the provider is prescribing a treatment rather than inviting the client to participate in determining what treatment will be best for him.

somewhat MI-Consistent: “Would you like to talk about treatment options that might help you regain your life?”

is provider utterance is somewhat MI-consistent. e provider asks the client permission to discuss treatment options. By asking permission and using the word “options,” the provider enhances the sense of collaboration and client autonomy. however, the provider does not seek to elicit the cli- ent’s desire, ability, reasons, need, or commitment for change before mov- ing to treatment planning. e provider also uses a closed question, which invites only a brief response from the client.

MI-Consistent: “So this has been really hard on you. Tell me a little about what has been di erent or bad about your life since the car accident.”

is provider utterance is MI-consistent, because it begins with an empathic re ection of the client’s comment about his life being ruined. e provider then invites the client to explain in more detail exactly how the car accident has negatively impacted him. e more change talk statements the provider elicits, the more likely the client will decide he is ready to commit to treatment (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003).

Proposed Strategy 4: Offering Choices

As outlined in chapter 2, a component of the foundational spirit of MI is accep- tance, which includes “autonomy support”—that is, provider support of the cli- ent’s right to choose the best course of action for him- or herself (see also Miller & Rollnick, 2013). us in discussing treatment, an MI-consistent provider should strive to o er objective information about options available to the client, including the potential pros and cons of each option. e provider should then

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collaborate with the client in deciding which course of action is best, keeping in mind that the client is the nal arbiter of what he or she will or will not do. As I (Js) advise the medical students each year during a brief lecture on practices and principles of MI, no matter what the treatment outcome literature and prac- tice guidelines say, a treatment that the client will not adhere to is probably not the best treatment for that client.

In the case of anxiety, trauma-related, and obsessive-compulsive disorders, cli- ents have many treatment options ranging from no treatment, to medications, to cognitive or behavioral psychotherapies, to supportive psychotherapy. Providers should be knowledgeable about treatment outcome data and practice guide- lines to o er clients accurate and objective information about the implications of selecting a particular intervention, completing between-session assignments, and/or dropping out of treatment before it is completed. Keep in mind that while it is MI-consistent for the provider to share his or her professional opinion about the best intervention option for a client (e.g., “Although what you decide is ulti- mately up to you, my professional opinion is that cognitive behavioral therapy would be a much better option for you than medication.”), it is MI-inconsistent for the provider to impose it on the client (e.g., “Cognitive behavioral therapy is really the only option for you.”).

Example: MI-Consistent/Inconsistent O ering Choices

e following examples with sanjay, the 18-year old with social anxiety, illustrate how a provider might o er choices to a client in an MI-consistent fashion.

Client statement: “I don’t see why I have to graduate high school. My father didn’t graduate and he makes a lot of money in construction.”

MI-Inconsistent: “ ings are di erent now, Sanjay. It is a lot harder to make a decent living without a diploma than it used to be.”

is statement is MI-inconsistent because instead of empathically acknowl- edging the client’s perspective, and perhaps inviting another perspective, the provider seeks to directly counter the client’s perspective and impose the provider’s perspective.

somewhat MI-Consistent: “Dropping out of high school is certainly an option.”

is statement is somewhat MI-consistent. e provider supports sanjay’s autonomy by acknowledging that dropping out of high school is an option. however, the provider does not present other options that might help sanjay move in his preferred direction. Although sanjay is expressing a desire to drop out, the desire seems to be driven largely if not entirely by a belief that dropping out is the only way to reduce his anxiety. As Miller and Rollnick (2013) note, there may be occasions when a provider uses MI to help a cli- ent consider goals in the client’s best interest, even when a client doesn’t initially endorse those goals.

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MI-Consistent: “ is has obviously become unbearable for you, Sanjay, and you feel like you need to do something. You have a lot of options in how to deal with this, and dropping out of school is certainly one of them. As a school counselor, my job is to help you select the solution that is best for you all things considered. I have some ideas of things that you may or may not think will be helpful to you, such as working with a counselor like me either alone or with your parents to learn skills and strategies to attend class without feeling anx- ious, talking to your doctor about medications that might help you manage your anxiety, scheduling meetings to talk to your teachers about the problems you’ve been having and asking for their help, talking to other students who used to have the same feelings you have about how they got past it. I will tell you my thoughts about the pros and cons of each of these options, but rst I’d like to hear your thoughts about these ideas and whether you maybe have some others we should put on the list for consideration.”

is provider utterance is MI-consistent, because it begins with an empathic re ection and then supports the client’s autonomy to choose his own solu- tion for the problem. It is further MI-consistent because rather than imme- diately telling the client what she thinks is best solution is, the provider rst lists available options and seeks his perspective on them.

Proposed Strategy 5: Emphasizing Control

Many providers who treat anxiety, trauma-related, and obsessive compulsive disorders recognize that avoidance is a symptom of the client’s disorder and thus feel compelled to push clients to work through and overcome it, doing so in a non-collaborative fashion that does not support client autonomy is MI-inconsistent. Although it is counterintuitive for many providers, we have found that emphasizing control when clients are having the most di culty engaging in treatment is a very useful strategy for helping clients overcome avoidance. In our experience, clients who are particularly uncertain about their ability to tolerate treatment may begin almost every in-session exposure practice with a statement of uncertainty and reluctance about continuing with treatment. is is followed, of course, by a statement from the provider sup- porting the client’s autonomy and right to choose what they do or do not do in a particular session.

Example: MI-Consistent/Inconsistent Emphasizing Control

e following example illustrates how a provider might use emphasizing control to address the clinical challenge of avoidance with Jamal, the man who is su ering from motor vehicle accident–related PTsD.

Client statement: “I’m not sure I can handle the exposure today.” MI-Inconsistent: “It is important for you to go on, Jamal.”

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is statement is MI-inconsistent because the provider does not acknowl- edge the client’s concerns or support his autonomy, and instead directly confronts his reluctance to participate in treatment.

somewhat MI-Consistent: “Why can’t you handle it, Jamal?”

is question is somewhat MI-consistent. It is an open question and thus elicits the client’s perspective. however, it is a question that elicits sustain talk, and thus will encourage the client to talk about why he can’t move toward his own treatment goals, rather than why he can. Additionally, the speci c wording of the question (“Why can’t you… ”) may be perceived as confrontational by the client. It implies that the provider thinks the client should be able to handle it.

MI-Consistent: “Jamal, you are in control here. It is entirely up to you whether you do the exposure today. As we’ve discussed before, you know that my recommendation is that you do it, because the more you confront what you fear, the less you will fear it. But ultimately it is up to you whether to do the practice today.”

is provider utterance is MI-consistent because although the provider reminds the client of previously discussed information about the impor- tance of completing exposure practices, the provider also repeatedly sup- ports the client’s autonomy and right to decide not to do the practice.

Proposed Strategy 6: Planning

As outlined further in the discussion of “Proposed strategy 7: envisioning,” many clients may underestimate the extent to which avoidance might interfere with their ability to successfully complete treatment for an anxiety, trauma-related, or obsessive compulsive disorder. helping a client prepare for the possibility that avoidance might interfere with his or her ability to participate in a desired treat- ment is another MI-consistent strategy for addressing this clinical challenge. As described in chapter 3, during MI-consistent planning the provider works col- laboratively with the client to devise strategies to address avoidance when and if it occurs. e provider should also revisit and update this plan as needed to ensure that the client is successful in achieving his or her goal of overcoming avoidance in order to successfully complete treatment.

Example: MI-Consistent/Inconsistent Planning

e following examples illustrate how a provider might use planning to help a client, such as Jamal, prepare to successfully overcome treatment avoidance.

Client statement: “I’m willing to give this treatment a try, but I’m not really sure about it.”

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MI-Inconsistent: “Jamal, your reluctance is probably based on avoidance, which is a symptom of posttraumatic stress disorder. You need to come to ses- sions regularly even if you don’t feel like it. Will you do that?”

Although the provider begins with information provision about avoidance, which is not MI-inconsistent, the provider goes on to tell the client what to do about the avoidance, which is MI-inconsistent. Telling the client what to do is not collaborative, and may diminish the client’s sense of autonomy.

somewhat MI-Consistent: “Jamal, I would recommend that you use breath- ing exercises and positive self-statements whenever you feel uncertain about treatment. But that may or may not be the best strategy for you.”

e provider o ers advice with permission to disregard, which is MI-consistent and promotes some sense of autonomy and collaboration. however, the response overall is only somewhat MI-consistent because the provider o ers this advice without rst eliciting Jamal’s thoughts about what might help him participate in treatment. us the collaboration is lukewarm.

MI-Consistent: “Jamal, if I may provide some information, your reluctance is probably based on avoidance, which is a symptom of posttraumatic stress disorder. Many clients who really want to overcome posttraumatic stress dis- order, but are uncertain about treatment nd it bene cial to discuss ahead of time what they will do if they begin nding it di cult to continue to treat- ment. Would it be okay if we did that now? [Provider waits for a rmative response]. Let’s start o by discussing what types of things might make you decide that treatment is too di cult or you don’t want to continue.”

is provider utterance is MI-consistent, because it begins with informa- tion provision and then segues into an invitation to the client to participate collaboratively in devising a strategy to address avoidance.

one way we have framed these plans in our own work is “Making a Plan for successful Treatment.” Change plan worksheets, such as the one in Table 6.4, are commonly used in MI (e.g., Miller & Rollnick, 2002).

Proposed Strategy 7: Envisioning

We have found that helping clients realistically envision what treatment might be like is o en a useful strategy for clients who have unrealistic expectations (see also chapter 5). given that the reality of treatment for most clients is that it is bene cial and manageable, but requires emotionally intense and perhaps time-consuming hard work, this strategy will o en result in clients voicing a small amount of sus- tain talk. An example of the type of utterance that might result from use of envi- sioning with a client who has unrealistic expectations of treatment might be, “I guess maybe the exposure practices might be hard, but if I think about how much it will help me, it will keep me going.” Although eliciting sustain talk is in most

Table 6.4. sample Plan for successful Treatment

Making a Plan for Successful Treatment-Example

e most important reasons why I want to successfully complete treatment are:

1. so I can get my life back.

2. so I can drive without fear.

3. so I stop thinking about the accident all the time.

4. so I don’t teach my kids to be afraid of driving.

To successfully complete treatment I must:*

1. Attend treatment regularly.

2. Complete in-session practices to the best of my ability.

3. Complete all homework assignments to the best of my ability.

Some things that could interfere with successful completion of treatment are:

1. My temper—sometimes when I get scared, I get angry and just say “forget about it”.

2. My priorities—I may decide that I need to work or do other things besides completing treatment.

3. something will happen with my family that makes me feel like I need to stop treatment.

4. I may talk myself out of it.

e ways other people can help me are:

1. My family can encourage me to keep going.

2. My therapist can encourage me and remind me that the end is in sight.

3. My therapist can call me if I miss an appointment and encourage me to reschedule.

What I will do if I am not “sticking with” treatment the way I had hoped or am considering dropping out:

1. Be honest with myself, and not blame other people for my part in this di culty.

2. Remind myself of how bad things were and how many times I’ve tricked myself into avoiding things because I’m anxious.

3. Remind myself that I am strong and I can do this!

4. Pray for strength, courage, patience, wisdom—whatever I need to make it through the di cult time.

5. Ask family, friends, and others for support and a pep talk.

6. Remember all the success I have had in treatment.

* Many ideas for what to list in this section may be o ered by the provider as the provider will be more knowledgeable about the components of the treatment the client has selected.

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cases an MI-inconsistent strategy, eliciting a small amount of sustain talk is some- times helpful in preparing clients who do not have a realistic perspective on the potential di culties of exposure-based treatment. Nonetheless, it is a strategy we recommend be used sparingly and only when clinical judgment suggests it is war- ranted. We personally use this strategy only when a client expresses a strong belief that an exposure-based treatment for anxiety will be easy and he cannot imagine encountering any di culties when completing it. For example, if a provider says, “ is exposure-based treatment for anxiety will involve repeatedly coming into contact with those things that make you most anxious and staying in the situa- tion for a predetermined amount of time, such as 30 minutes, or until your anxi- ety diminished by 50%. What questions or concerns do you have?” If the client says, “I don’t have any concerns, it sounds straightforward. let’s get started,” the provider may wish to help the client better envision what treatment will really be like and gain a more realistic perspective on the treatment. is will help ensure that the client is not disappointed, or does not feel like a failure if he or she does experience di culty with treatment at some later point.

Example: MI-Consistent/Inconsistent Envisioning

e following examples illustrate this likely controversial, but potentially very useful strategy as a provider and client discuss treatment for posttrau- matic stress disorder.

Client statement: “I don’t have any concerns. PTSD has ruined my life and I’ll do anything it takes to get past it.”

MI-Inconsistent: It doesn’t sound like you are being very honest with yourself.”

is provider utterance is MI-inconsistent because the provider directly confronts the client’s optimism, which is not collaborative and does not support the client’s autonomy.

somewhat MI-Consistent: “Tell me one concern that you might have about PTSD treatment.”

is provider utterance is somewhat MI-consistent. It is an open question (“tell me” statements are considered open questions in MI) and thus invites a lengthy answer from the client. however, given the context (the client has just stated “I don’t have any concerns”), it is likely to elicit discord. e cli- ent may feel that the provider is not listening—or worse yet, may feel con- fronted by the provider.

MI-Consistent: “So you are very con dent and ready to go. Many people who go through this treatment nd that it is more di cult or more intense than they expected. What do you think might happen in treatment that might make you feel less certain about wanting to continue with it?”

Although the provider is likely to elicit a small amount of sustain talk by asking the client to envision what might be di cult in treatment, which as stated is not strictly MI-consistent, the provider does so in an MI-consistent

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fashion. e provider rst empathically re ects the client’s optimism and then objectively provides information that does not directly counter what the client has said, but perhaps gives him food for thought. Finally, the pro- vider asks an open question seeking to elicit the client’s perspective on what might happen that might be di cult in treatment. is then allows the pro- vider to work with the client to plan for and successfully overcome these barriers as discussed in Proposed strategy 6.

CLINICAL CHALLENGE 3: PSYCHOTIC SYMPTOMS

Description

Psychosis refers to a loss of contact with reality that usually includes false beliefs about what is taking place or who one is (delusions) or seeing, hearing, smelling, tasting, or feeling things that aren’t there (hallucinations). In addition to hallucina- tions and delusions, other symptoms of psychosis include disorganized thoughts, speech, and behavior. Psychosis can be caused by a number of medical problems, such as alcohol and drug use or withdrawal, and diseases or tumors that a ect the brain, as well as psychiatric disorders such as schizophrenia, bipolar disorder, severe depression, and some personality disorders. Although treatment depends on the cause of the psychosis, it typically includes an antipsychotic medication (Cohen, 2010). MI shows promise for helping individuals with psychotic disorders, particularly schizophrenia, better adhere to necessary medications (Drymalski & Campbell, 2009) and make other positive changes in their lives, such as decreased problematic alcohol consumption (graeber, Moyers, gri th, guajardo, & Tonigan, 2003) and increased contact with smoking cessation professionals (steinberg, Ziedonis, Krejci, & Brandon, 2004). Nonetheless, psychotic symptoms and disorders present unique challenges to the implementation of MI (e.g., Rusch & Corrigan, 2002). More than once community providers have tried to “stump” us by role playing a client with psychotic symptoms during a training event.

example: Roger is a 63-year-old man who has been diagnosed with schizo- phrenia and is being cared for in a board and care home. Roger’s adherence to his antipsychotic medications has varied over the past 40 years. During peri- ods of lower adherence, he o en spends months or years living on the street until his family tracks him down and he is admitted to an inpatient psychi- atric facility for stabilization. Recently, Roger’s physical health has worsened, and the sta at the board and care home believe Roger will need to be cared for in a skilled nursing facility. For example, due to his medical condition Roger o en falls. Because of his large stature, Regina, the weekend house manager at the board and care facility (a petite woman), has di culty assisting Roger when this occurs. is di culty is compounded by the fact that Roger is o en shouting incoherently a er a fall and has di culty responding to Regina’s

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instructions. Roger seems to have little insight into his physical health con- cerns, and has dismissed sta attempts to initiate discussions with him about their concerns. Almost as soon as these discussions are initiated, Roger insists that he is in peak physical condition because the CIA has injected him with experimental drugs to enhance his performance.

how would you respond to Roger? Would you argue with Roger about the unreality of his beliefs? Would you recommend that the psychiatrist increase his medications so he is too sedated to leave his bed? Would you go to the court to have Roger committed to a nursing home for his own safety? Would you quit your job at the board and care home and nd a less stressful position? e text will outline several MI-consistent strategies that may be useful when working with clients who have delusions, hallucinations, or disorganized thoughts and behaviors. however, it is important to note that adaptations to commonly used MI strategies are o en necessary when working with individuals who su er from psychotic symptoms or disorders. Carey, leontieva, Dimmock, Maisto, and Batki (2007) have recommended adapting motivational enhancement protocols for individuals with schizophrenia to include more frequent, briefer sessions. Carey and colleagues describe the potential bene ts of this adaptation for clients with schizophrenia as: (1) decreased demands on attention; (2) increased oppor- tunities for clients to learn how to respond to an MI-style intervention; (3) greater repetition of and elaboration of content; (4) better integration of real-life events into discussions; and (5) attenuated impact of a “bad day” (e.g., a day on which symptoms or stressors are much worse) on overall treatment outcome. Martino, Carroll, Kostas, Perkins, and Rounsaville (2002) recommend several adapta- tions of MI for individuals with psychotic disorders to accommodate disordered thinking and cognitive impairments, such as simplifying open-ended questions (e.g., avoiding compound questions), emphasizing the provider role in guiding the conversation to promote logical organization and reality testing, reducing re ections focused on disturbing life experiences, and increasing emphasis on a rmations of the client. It is important to note that many of these strategies as well as those presented here, are less appropriate or less e ective for clients who are highly disorganized or agitated.

Proposed Strategy 1: Giving Information

It has been our experience that some clients who have been involved in the medi- cal, substance abuse treatment, or criminal justice systems for a long period of time experience initial surprise or uncertainty when working with a provider who is using an MI-consistent approach. For example, they may provide very short answers in response to open questions or sit in silence a er a provider o ers a re ective listening statement. Client uncertainty is not surprising given how dis- similar MI is from many of the directive approaches most commonly employed in those settings and from interpersonal interactions in general (Amrhein et al.,

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2003). Despite this initial uncertainty, we have found that most of these clients readily adapt to MI spirit and techniques, and very actively and fully participate in the interaction within a few minutes. As Martino and colleagues (2002) note, individuals with disordered or disorganized thinking may have more di culty adapting readily to an MI style. us, they recommend providing the client with an informative overview prior to an MI-style interaction. During this overview the client is informed not only of the purpose of the interaction, but also the roles that the client and provider will have during the interaction.

Example: MI-Consistent/Inconsistent Giving Information

e following examples illustrate how giving information can be used to orient clients with cognitive impairments to an MI-style interaction.

Client statement: “How long is this going to take? I haven’t had a cigarette in hours.”

MI-Inconsistent: “Roger, you can have a cigarette a er we’re done. e sta has decided that we can no longer care for you here. We are going to recom- mend to your case worker that you be placed in a skilled nursing facility. Do you have any questions?”

is provider utterance is MI-inconsistent because the provider does not attempt to collaborate with Roger. Instead the provider dismisses Roger’s request for information about the length of the appointment and his obvi- ous desire for a smoke break. en the provider assumes the expert role and tells Roger that a decision has been made about his care. e nal question is almost MI-consistent, in that the provider seeks to get Roger’s perspective on what he has just been told, but it is phrased as a closed question, which invites Roger to provide only a brief answer (e.g., “yes” or “no”) rather than a more lengthy response.

somewhat MI-Consistent: “ is will take about 15 minutes Roger.”

is provider response is somewhat MI-consistent in that the provider answers the client’s question in an objective fashion. however, the provider does not ask the client’s permission to continue the interaction or provide any information about the purpose of the interaction and thus does not support the client’s autonomy or set the stage for the client to collaborate in the interaction.

MI-Consistent: “I know you really want a cigarette right now, and at the same time I’d really like about 15 minutes of your time to discuss something important. Would that be okay? [Waits for client response]. Roger, I’d like to talk to you a little bit about the good experiences and not-so-good experi- ences you’ve had with us over the last few months and what the best options for housing might be for you. I’m really interested in learning about what you think and feel about your housing, so although I may ask you a few questions here and there, I’m really just interested in hearing what you have to say. Tell me what you like about living in this house, Roger.”

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is provider utterance is MI-consistent because it begins with a re ection of Roger’s desire for a cigarette and an answer to his question. is demon- strates empathy and also establishes a collaborative atmosphere. e pro- vider asks Roger’s permission to continue the interaction, which supports Roger’s autonomy and further promotes a collaborative atmosphere. e provider then o ers Roger information to help orient Roger to an MI-style interaction during which the pros and cons of his current living arrange- ment will be reviewed. is should prepare Roger to collaborate more actively in the discussion. It is important to note that using an MI style does not guarantee that Roger will agree with the sta ’s determination that they are no longer able to provide adequate, safe care for him and that it is time for him to move to another type of facility. us the sta at the board and care home may ultimately have to go against Roger’s wishes to stay at their facility. Nonetheless, engaging Roger in a discussion that invites his perspective and allows him to control those aspects of the situation that are under his control (e.g., the location of the facility to which he transfers) sup- port and emphasize the autonomy that Roger does have.

Proposed Strategy 2: Asking Permission

Asking permission before giving information or advice is an MI-consistent strat- egy to increase the sense of collaboration and support of client autonomy during an interaction (Moyers, Martin, Manuel, Miller, & ernst, 2010). Asking permis- sion can also help add additional structure to an interaction when clients have di culty keeping their own thoughts or speech organized. is approach is not uncommon in standard implementation of MI and MI hybrid interventions such as motivational enhancement (Miller et al., 1992) or motivational interviewing assessment (Martino et al., 2006). For example, in an MI session, the transition from eliciting to planning might be marked by a provider utterance such as “If it is okay with you, I’d like to shi gears and begin developing a plan for help- ing your reach your goals.” however, more frequent use of such utterances than would be typical may be bene cial for clients who have di culty sustaining as structured, focused dialogue on a particular topic.

Example: MI-Consistent/Inconsistent Asking Permission

e following examples illustrate how a provider might use giving informa- tion to help a client maintain focus throughout the session:

Client statement: “I’ve been taking my medications every day. ere’s no problem with that.”

MI-Inconsistent: “I know you are taking them right now, Roger, but it is important for us to talk about the times you haven’t been taking them. Every time you stop taking them you decompensate.”

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Although the provider acknowledges the client’s recent success with medication adherence, which is MI-consistent, the provider quickly dis- misses this success and shi s the focus in a non-collaborative fashion to times the client has been less successful, which is MI-inconsistent. e provider then o ers information about medication adherence not to inform the client, but to confront him about the problems his past behavior has caused.

somewhat MI-Consistent: “If it’s okay with you, I’d like for us to talk about the times when you haven’t been taking your medication.”

is statement is somewhat MI-consistent because the provider seeks the client’s permission to discuss medication adherence. however, given that the client has just stated that he has been compliant with his medication, the speci c wording of this utterance is likely to be perceived by the cli- ent as non-collaborative. e provider also misses an excellent opportu- nity to a rm a client who is obviously seeking positive feedback from the provider.

MI-Consistent: “You’ve been quite successful with your medications for the last several months, Roger. at’s really impressive. If it’s okay with you I’d like to spend at least a few minutes talking about what has sometimes made it hard to be successful in the past. Many clients nd their symp- toms worsen and they lose a lot of progress when they stop taking their medications.”

is provider utterance is MI-consistent because it begins with an a rma- tion of the client’s success. e provider then asks permission to change the topic to possible reasons for past adherence, but is careful to do so in a way that does not diminish the prior a rmation of the client’s success. e provider also o ers information about the importance of discussing medi- cation adherence, but does so in the third person, which makes it less likely to arouse defensiveness (Rollnick et al., 2008).

Proposed Strategy 3: Summarizing

As noted in chapter 2, summaries are an opportunity for the provider to pull together and synthesize several of statements the client has made. When used in MI, summaries are o en selective. at is, the provider may choose to include key points the client has made, such as “change talk” statements, while omitting other things the client has said that are less relevant to the focus of the interac- tion. Martino et al. (2002) suggest that summaries can be used to provide logical organization to client statements. us, with clients who may have disorganized or tangential thinking, a careful summary can be used to organize a client’s thoughts for him or her. Not surprisingly, re ecting or summarizing is much more challenging for providers who work with clients su ering from psychotic disorders (Martino et al., 2002), and thus may be di cult for those who are new to MI to implement e ectively.

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Example: MI-Consistent/Inconsistent Summarizing

e following examples illustrate how a provider might use summarizing to help a client organize his or her thoughts in a meaningful way.

Client statement: “I’ve been taking my medications every day. ere’s no problem with that. My case worker just wants me to go to the nursing home because she works for ‘them.’ I think she’s been poisoning me. at’s probably why I’m falling. e drugs the CIA gives me have been helping. I think they must be an antidote. Can I have a smoke break? I get really nervous when I can’t smoke. I think the CIA agent is coming back tomorrow. Can you call my case worker? I want to see my sister.”

MI-Inconsistent: “Roger, you know the CIA isn’t giving you any medications.”

is statement is not a summary and is MI-inconsistent because the pro- vider directly confronts the client’s delusional thinking. Although the pro- vider is accurate, the manner in which he addresses the client’s delusional thinking is not collaborative and diminishes his sense of autonomy.

somewhat MI-consistent: “So you think she’s been poisoning you and that she works for them.”

is statement is somewhat MI-consistent because the provider summa- rizes a portion of what the client has said. however, the material summa- rized is unlikely to move the client toward positive change. Instead, the summary is likely to get the client to expound upon his delusional beliefs.

MI-Consistent: “You’ve been quite successful with your medications for the last several months, Roger. It seems like it is important to you to take care of yourself. I’m hearing that the falls are concerning to you, but you are less convinced that the nursing home is the solution. It sounds like the case worker has talked to you a bit about why the sta has recommended that for you. Would it be okay if I shared a little bit more about the types of bene ts we thought a nursing home might have for you?”

is provider utterance is MI-consistent because the provider selectively re ects statements the client made that support positive, healthy changes. e provider re ects on the client’s medication adherence and guesses that this might re ect an underlying desire he has to take care of his health. e provider also re ects the client’s brief mention about the falls as a potential concern. Finally, the provider asks the client’s permission to share additional information about the sta ’s recommendation. is supports client auton- omy and sets the tone for a collaborative discussion about the nursing home.

Proposed Strategy 4: Re ective Listening

In our work training providers who work with individuals who have delu- sional thinking, one issue that appears particularly challenging is how to stay

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MI-consistent without colluding with the delusions—that is, without provid- ing additional evidence to support the delusional belief (Nelson, 2005). During training role plays, when the “client” makes a delusional statement such as: “ e house manager stole my sweater!” we nd that providers generally respond in one of two ways: (1) they calmly, but directly confront the client statement: “No, she didn’t. No one is stealing from you.” in an e ort to help bring the client back into contact with reality; or (2) they re ect the delusional content as though it were reality-based: “ e house manager stole your sweater.” e rst state- ment avoids supporting a delusional belief, but is likely to increase discord in the provider-client interaction. Although more MI-consistent, the second state- ment may serve to reinforce the client’s inaccurate paranoid beliefs about the house manager and encourage the client to continue talking about them. Instead of direct confrontation or collusion, we recommend that providers strategically re ect whatever aspect of the client statement or interaction is reality based. In some cases, the emotion that seems to underlie the client’s statements (e.g., fear, anger) or the process unfolding between the client and provider (e.g., frustration, misunderstanding) may be the only reality-based material available. An example would be: “You sometimes feel unsure of who you can trust.”

Example: MI-Consistent/Inconsistent Re ective Listening

e following examples illustrate how a provider might use re ecting to emphasize reality-based statements by a client who has disorganized or delusional thinking.

Client statement: “My case worker just wants me to go to the nursing home because she works for “them.” I think she’s been poisoning me.”

MI-Inconsistent: “Roger, you know the case worker is not poisoning you.”

is statement is not a re ection and is MI-inconsistent. Although the pro- vider is accurate, her direct confrontation of the client’s delusional thinking is not collaborative and diminishes his sense of autonomy.

somewhat MI-Consistent: “Roger that must be very frightening to have the case worker out to get you.”

is statement is a re ection and technically is MI-consistent. however, because it is a re ection of a delusional belief, it does not help move the cli- ent in a direction of positive change. Instead, it may serve to more deeply entrench the client’s delusional beliefs, as a person of authority has agreed with them (Nelson, 2005).

MI-Consistent: “You’re not convinced that a nursing home is the right place- ment for you, so you question the sta ’s motives for recommending one.”

is provider utterance is MI-consistent because the provider re ects the client’s disagreement about the appropriateness of a nursing home and his di culty accepting the sta ’s recommendation given that he doesn’t agree with their appraisal of his physical condition. e statement does not directly confront the delusional belief, nor does it in any way support

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the client’s erroneous belief that he is being poisoned or that the case worker is aligned with some nefarious organization. e utterance also helps guide the client toward a meaningful discussion of a key issue that sta needs to discuss with him—the recommendation for placement in a nursing home.

Proposed Strategy 5: Shifting Focus

sometimes a client with psychotic symptoms is so caught up in a pattern of delusional or disorganized thinking that the best strategy may be helping the client shi attention away from the disorganized or delusional pattern of thinking. An MI strategy termed “shi ing focus” can be very helpful in this regard. As Miller and Rollnick (2002) highlight, this strategy amounts to going around the barrier to productive discussion rather than trying to climb over it. It is important to note that when this strategy is applied in an MI-consistent fashion, it typically involves rst acknowledging the cli- ent’s concern and then guiding the client to a discussion of a workable issue. Without acknowledgement of the client’s concern (be it reality-based or not), this strategy has the potential to cast the provider in the expert role and the client in a passive role.

Example: MI-Consistent/Inconsistent Shi ing Focus

e following examples illustrate how a provider might use shi ing focus in an MI-consistent fashion to help a client who is stuck in a pattern of delu- sional or disorganized thinking.

Client statement: “My case worker just wants me to go to the nursing home because she works for ‘them.’ I think she’s been poisoning me.”

MI-Inconsistent: “ at’s not really why I called you here today. I called you here today because we need to talk to you about your medical issues.”

is provider utterance is MI-inconsistent because the provider actively dismisses the client’s concerns and shi s to the topic of medical concerns in a very non-collaborative fashion. is approach is likely to promote discord between client and the provider or cause the client to assume a passive role in the interaction.

somewhat MI-Consistent: “So you’re still worried about your case worker. What do you think we should do about that?”

In this response the provider rst re ects what the client has said and then asks a question to gather more information. us, the response is somewhat MI-consistent. however, what the provider chooses to re ect and the question the provider chooses to ask focus the discussion on a

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topic that is not likely to lead to positive change. since the case worker is not really poisoning the client, developing solutions to that problem is likely to have little bene t for the client and may increase the intensity of his delusional beliefs.

MI-Consistent: “You don’t feel like a nursing home is going to be the best t for you, and you’re questioning the case worker’s motive for recommending it. What are the important things you are looking for in a place to live?”

is provider utterance is MI-consistent because the provider acknowl- edges the client’s concerns using re ective listening. Note that the provider empathically re ected the client’s concerns without agreeing either implic- itly or explicitly that he is being poisoned or that his case worker works for “them.” e provider then uses an open question to help shi focus to a workable, but related issue: what characteristics the client looks for in a place to live.

Proposed Strategy 6: Stacked Questions

Martino et al. (2002) recommend simplifying open questions for clients with schizophrenia. speci cally, they recommend avoiding complex open questions such as, “What do you think your family would think about the nursing home and how does that impact your willingness to consider it?” A complex open question such as that can be di cult even for very high functioning individual with no cognitive impairments. I (Js) remember a time when a grand rounds speaker in our department was asked a compound open question, and as one might expect, she responded to the rst part of the question and then had to ask the questioner to repeat the second part of the question because she had forgot- ten it. For clients who have problems with organizing their thinking, these types of questions can be very confusing and overwhelming. simple phrasing of open questions, such as: “What do you think your family would think about the nurs- ing home?” [Waits for client response]. “how does that impact your willingness to consider a nursing home?” are likely to be much more e ective.

It has been our experience that even when phrased simply, clients with cog- nitive impairments such as disorganized thinking may have some di culty responding to open questions. sometimes, even with a simple open question, the client may feel unsure of what is being asked. e use of stacked questions can help clients who have di culty responding to simple open questions. Asking the client an open question followed by a series of closed questions intended to give the client a sense of what types of answers would address the open question can be useful in this situation. is has been referred to as stacked questions (Moyers et al. 2010) and is useful because it gives a client the con dence and certainty to respond to an open question without narrowing the focus in the way a closed question does.

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Example: MI-Consistent/Inconsistent Stacked Questions

e following examples illustrate how a provider might use stacked ques- tions to help a client who is having di culty responding to open questions.

Client statement: “My case worker just wants me to go to the nursing home because she works for ‘them.’ I think she’s been poisoning me.”

MI-Inconsistent: “Poisoning you? Are you sure? ere isn’t any evidence for that is there, Roger?”

is provider utterance includes stacked questions, but is not MI-consistent. All of the questions are a direct confrontation of the client’s statement. is diminishes the client’s sense of autonomy as well as the sense of collabo- ration in the interview. Additionally, the questions keep the focus on the delusional content, instead of trying to guide the client toward a more pro- ductive discussion of the pressing issue at hand—how the client would like to handle his need for greater medical care than the board and care home can provide.

somewhat MI-Consistent: “What do you want to do? Do you want to go to the nursing home? Or do you want to see if your sister will let you move in with her?”

is response is somewhat MI-consistent. e provider starts o with an open question that invites the client to share his preferences. By asking what the client wants, the provider also o ers some support for client autonomy by expressing that what the client wants matters. however, instead of pro- viding the client with a menu of possible ways to answer the open ques- tion, the closed questions that follow the initial question serve to narrow the range of possible answers to the question.

MI-Consistent: “What bene ts might there be to moving somewhere like a nursing home? For example, wouldn’t it be nice to have people available 24-7 when you aren’t feeling well? Would it be good to be somewhere closer to your family? Would you feel less anxious if you had your own room rather than having to share? . . .

is provider utterance is MI-consistent because the provider asks an open question to gain the client’s perspective. even though the open question is followed by closed questions, the intent of these questions is to provide the client with clarity about the spirit of the provider’s question as well as the sense that there are a range of “right” answers to the question that has been posed. is may enhance the client’s ability and con dence to provide a meaningful answer to the question and thus collaborate actively with the provider in exploring the pros and cons of an alternative housing situation, such as a nursing home.

Table 6.5. summary of Motivational Interviewing strategies for Clinical Challenges Related to Psychiatric symptoms

Clinical Challenge

Suggested MI Strategies

Depression:

Clients su ering from depression experience hopelessness, feelings of worthlessness or guilt, di culty concentrating, and lack of interest in activities that may make it di cult for them to fully engage with a provider or change process.

hypothetical Questions: hypothetical questions invite
a client to consider the possibility of change without committing to it. ese questions can help clients who are feeling hopeless consider potential solutions or bene ts of change, even if they are currently feeling pessimistic about the possibility of change.

Planning: Planning involves helping a client think through the concrete details of how desired change will be accomplished. A concrete plan may help clients who are feeling pessimistic become more hopeful about the possibility of change.

envisioning: envisioning involves asking a client to imagine what the future would be like if they were to make a change. is strategy may be helpful for clients who respond to questions about past negative consequences
of their behavior in an overly self-deprecating fashion because they are experiencing excessive guilt or feelings of worthlessness.

A rming: A rmations, which involve commenting on a client’s strengths or abilities in any area, can help clients experiencing feelings of worthlessness or guilt to view themselves as capable of change.

summarizing: Frequent summaries of key points in the conversation may enhance engagement for clients who have di culty concentrating.

handouts: Providing clients who have di culty concentrating with MI-consistent handouts, such as a decisional balance or change plan, may help them better remember key points covered during a conversation about change.

looking Back: Asking a client to think about what things were like before their depression emerged can help clients who currently lack interest in activities to identify activities they might enjoy or nd rewarding.

(continued)

Table 6.5. CoNTINUeD

Clinical Challenge

Suggested MI Strategies

Anxiety:

Clients diagnosed with anxiety or related disorders may avoid
essential aspects of treatment, including appointments

with their provider, because participating fully in treatment causes anxiety or distress.

empathic listening: listening carefully to a client in an attempt to really understand his or her perspective may help a provider to fully appreciate that the distress associated with anxiety and related disorders is more than the nervousness we all experience in certain situations.

Assessment Feedback: Providing clients with objective feedback on an anxiety assessment may help clients better recognize the ways in which anxiety and related disorders are impacting their lives.

evocation: Using evocative questions to help a client articulate his or her reasons for change may help a client who has not been fully participating in an intervention due to anxiety develop su cient motivation to endure the intervention despite their anxiety.

o ering Choices: o ering the client choices about intervention options available to him or her enables the client to choose the intervention option that is best for him or her all things (including anxiety) considered.

emphasizing Control: emphasizing that the client is the one who ultimately has to choose what he or she will or will not do may help empower a client who is avoiding treatment due to anxiety or related disorders to actively engage in treatment despite their distress.

Planning: Clients who may avoid treatment due to symptoms of anxiety or related disorders may bene t from making a plan for what they will do if they nd themselves considering avoiding an appointment or other treatment activity.

envisioning: helping a client envision what treatment can be like may be helpful to clients who su er from anxiety or related disorders and underestimate how di cult treatment might be given their symptoms.

Psychotic symptoms:

Clients who experience symptoms
of psychotic disorders including disorganized

giving Information: Before attempting to utilize MI-consistent strategies with an individual su ering from psychotic symptoms, it can be helpful to give information about the type of conversation you are hoping to have with the individual. Many MI-consistent strategies are so unlike typical communication strategies that they might lead to confusion or uncertainty without this preface.

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Clinical Challenge

Suggested MI Strategies

thoughts, speech, and behavior, as
well as delusions, may have di culty actively participating in many types of interventions.

Asking Permission: Asking permission to discuss
a particular topic may a useful strategy for guiding disorganized clients back to the topic of discussion each time the discussion veers o topic.

summarizing: Using summaries may be helpful when working with clients who have disorganized thinking. With a summary the provider may help the client organize his or her thoughts in a meaningful way.

Re ective listening: Providers may use re ections to selectively emphasize reality-based content embedded within a delusional client utterance.

shi ing Focus: A provider may use an open question to shi the focus from a tangential or delusion topic to a topic that is more likely to guide the client in the direction of positive change.

stacked Questions: some clients with thought disorders may be uncertain how to respond to open questions. Following an open question with a series of closed questions that seek to clarify the intent of the question for a client may be helpful for clients who feel uncertain of how they should respond to the open question.

CHAPTER SUMMARY

In our own work, we have found that the principles and practices of MI can be very fruitfully applied to some of the unique challenges encountered when work- ing with clients who are experiencing psychiatric symptoms or disorders. ese challenges include things such as hopelessness, lack of interest in activities, dif- culty concentrating, avoidance, and disorganized or delusional thinking. given that psychiatric illnesses are very common, mental health professionals are not the only ones likely to encounter these unique challenges. us we attempted to provide practical, non-technical descriptions of these symptoms and disorders so that non–mental health providers can more readily identify clients who may bene t from referral to mental health treatment and who may also bene t from MI-consistent strategies to help them overcome barriers to change introduced by their psychiatric illness. A summary of these strategies can be found in Table 6.5.

7

Working with Multiple Individuals

Up to this point we have discussed clinical challenges related to working with one individual. however, many providers work with multiple individuals simultaneously. is work may take the form of seeing a couple about marital issues or parenting, providing education to a group of clients, or facilitating disorder-speci c treatment groups. Working with more than one person in an MI-consistent way requires simultaneously attending to a variety of concerns and client factors. us, the MI-consistent provider needs to attend to things like ambivalence, change talk, sustain talk, and discord as they uniquely apply to each individual. It is likely that these variables are di erent for each person. In other words, a provider cannot assume that there is a “shared” level of ambiva- lence among all clients involved in an interaction. Moreover, even if all clients are experiencing an equal level of ambivalence, this will be experienced di er- ently by each individual. however, the MI-consistent provider must avoid simply doing “individual MI” for each person. us the question becomes, how does the provider consider each individual’s goals, ambivalence, and needs in the context of working with multiple individuals? Furthermore, how does the provider bal- ance these various goals and needs to keep the interaction moving forward?

As a means of helping you consider how to address this challenge, we present two unique clinical challenges related to working with multiple individuals— working with parents and working with groups. We want to emphasize that our focus in this chapter is on how to address challenges that arise when working with parents and groups in an MI-consistent way. We are not, however, provid- ing guidance on developing MI-based interventions for parents or groups.

CLINICAL CHALLENGE 1: PARENTS Description

We have many colleagues who work with children and o er behavioral par- ent training as part of their clinical services. ese colleagues frequently tell us about their struggles to engage parents in parent training, especially when they expect that their child will be the only one meeting with the provider and making

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changes. Although it is important to consider parent preferences in selecting an intervention strategy for child behavior problems, our colleagues o en express that working with only the child will result in sub-optimal outcomes. In fact, multiple approaches to addressing child behavior problems, including parent training, tend to be the best approach (Curtis, Ronan, & Borduin, 2004). For example, parent training programs are among the most robust, empirically sup- ported interventions available for preventing, and even reversing, development of antisocial behavior in youth (Kazdin, 2005; Maughan, Christiansen, Jenson, olympia, & Clark, 2005). A wide range of positive outcomes have been associated with parent training programs including reduced behavior problems, increased social competence, and improved academic performance among children. Positive e ects for participating parents also have been demonstrated, includ- ing improved parent-child relationships, reduced parenting stress, and reduced use of corporal punishment (e.g., Nicholson Fox, & Johnson, 2005). us, from a provider perspective, parent training programs would in many cases be consid- ered an optimal rst-line approach to addressing child behavior problems.

While parent training programs are promising, engaging parents in parent training programs and reducing attrition rates is di cult (sterrett, Jones, Zalot, & shook, 2010). Parents participating in parent training classes or interven- tions are most o en seeking services because of a perceived (and o en, actual) child behavior problem such as noncompliance or aggression. In parent training classes, the focus is on the parent as the agent through whom change in the child is facilitated, which may be di cult for parents, who are focused on the child, to accept. is creates a discrepancy between the parents and the provider as to what the problem is and how to address the problem. As discussed in chapter 2 discrepancies between clients and providers are likely to produce discord and increase client sustain talk. Complicating the situation, discrepancies between parents about the degree to which they need to learn di erent parenting skills may exist. one parent may see the need to change her parenting skills whereas her partner may see no need to learn new skills. us, the couple is not on the same page in relation to what needs to be changed, and this may hinder engage- ment and retention in parent training. In these two situations it might be help- ful to consider that one or both members of the couple are pre-contemplative about their need to change their parenting practices. Adopting an MI-consistent approach to discussing the option of parent training may help to address the common pitfalls in parent training.

example: Margo and Phil have an 11-year-old son, Benjamin. Benjamin has been referred to a behavior specialist by his endocrinologist to better man- age his diabetes. Benjamin was diagnosed with type 1 diabetes 2 years ago and it has worsened in the past 6 months. Upon meeting Benjamin and his parents, the behavior specialist learns that Margo and Phil disagree on how much they need to monitor and manage Benjamin’s adherence to his medi- cal treatment plan, including his diet. Margo will o en monitor Benjamin’s diet and ensure he is taking his medications. On the other hand, Phil believes

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that Benjamin is old enough to monitor these behaviors. Phil also believes that ‘Ben should be able to be a normal kid’ and o en allows Benjamin to eat whatever he wants. us, Benjamin o en abides what his father says and rarely manages his behavior in relation to his health. is behavior has led to a worsening of Benjamin’s diabetes to the point their physician has become concerned.”

is example is not uncommon when parents bring their children for assis- tance with behavioral concerns. Parents may not have made the association between their behavior and their child’s behavior. Using some of the following MI strategies may help parents make this link without becoming defensive and ultimately help their child develop healthier behaviors.

Proposed Strategy 1: Providing Feedback and Information

o en parents are less aware of how their behavior or parenting practices may have contributed to the development and maintenance of their child’s behav- ioral problems. one approach to addressing this lack of awareness is to pro- vide parents with information about how multiple factors, including parenting practices, in uence a child’s behavior and the problems displayed. For instance, the Family Check-up is an MI-based approach that includes feedback and has empirical support (Brennan, shelleby, shaw, gardner, Dishion, & Wilson, 2013; smith, Dishion, shaw, & Wilson 2013). giving information is a valuable strategy in MI, and it is how the information is provided that makes the strategy more or less MI-consistent. In particular, it is important that the information-giving pro- cess is engaging and objective. Additionally, information would generally only be o ered a er asking permission or being invited to share the information. In relation to parenting, it seems important to o er information to clients in a fash- ion that attempts to minimize any defensiveness or perception of being blamed for the child’s problems.

Example: MI-Consistent/Inconsistent Giving Information

e following examples will illustrate MI-consistent and MI-inconsistent strategies for giving information to clients who are ambivalent about engag- ing in parent training.

Client statement: “Margo tends to micromanage everything Benjamin does. It seems like he needs more space to be himself and be a normal kid.

MI-Inconsistent: “Well, Benjamin certainly is at an age where he needs to learn to better care for himself. Kids typically learn self-management behaviors from their parents and your doctor is concerned that you and Margo are not helping Benjamin to better manage his diabetes. O en when problems like these hap- pen, parents need to change some of their parenting strategies to help their child.”

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is statement gives the client some information about the connection between child and parent behavior. e provider even supports the cli- ent’s perspective a bit. however, the way in which the information is provided is MI-inconsistent. e provider simply o ers the informa- tion without asking permission, announcing or emphasizing personal control in providing the information. ere is a potential for the infor- mation to be received as blaming by the clients, which could increase discord. Finally, the provider does not elicit the clients’ responses to this information.

somewhat MI-Consistent: “You two are concerned about Benjamin and his health and have di erent opinions about how to help him manage his behav- ior. If it’s okay with you, I’d like share some information we know about chil- dren and managing health behavior. [Waits for client response]. One thing we know is that it is important for mom and dad to have a shared perspective of how to manage their child’s behavior. Sometimes when parents modify their behavior a bit, it has a remarkable e ect on the child’s behavior. I’ve got a list of strategies that will help you get on the same page.”

is provider statement is somewhat MI-consistent because it empa- thizes and a rms the parents and elicits a response to the information from both parents. e provider also asks permission and presents the information in a non-expert role. however, a er presenting the informa- tion about the importance of a shared perspective, the provider does not elicit the reactions from each parent to the information before presenting the list of strategies. As a result, the information-sharing process is less engaging and may result in discord.

MI-Consistent: “You two are concerned about Benjamin and his health. You have di erent opinions about how to help him manage his behavior. If it’s okay with you, I’d like share some information we know about children and managing health behavior. [Waits for client response]. One thing we know from a professional perspective is that when mom and dad don’t have a shared vision of how to manage the behavior that the child’s behavior can become more problematic. Sometimes when parents modify their behavior a bit it has a remarkable e ect on the child’s behavior. What do you two think about this information?”

e provider o ers this information in a MI-consistent way. e pro- vider begins by a rming the parents’ dedication and concern for their child. Next, the provider re ects the discrepancy between the parent’s view of the problem [and possibly solution]. is is done in a way that doesn’t side with either parent. Before o ering information, the provider announces that he would like to share information. e provider gives the information in the third person, in the context of what is known in the professional world versus speci cally focusing on the parents, which

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can decrease perceptions of blame or defensiveness. Finally, the provider elicits the reaction from the parents to this information.

Proposed Strategy 2: Exploring Goals/Values

sometimes parents are less aware of how their parenting practices might have an e ect on their goals for their children. Provider-client discussions that invite clients to share their goals for their children and how their behavior facilitates or hinders achievement of these goals might help clients make key connections on their own. such discussions can also help parents begin to consider what may need to happen to support the achievement of their goals for their child. A related approach is to explore the parents’ values in relation to caring for their children and compare how current behaviors are in line or not with those parenting values. In MI these strategies are called exploring goals/values.

Example: MI-Consistent/Inconsistent Exploring Goals

e following examples will illustrate MI-consistent and MI-inconsistent exploring of goals or values.

Client statement: “Margo tends to micromanage everything Benjamin does. It seems like he needs more space to be himself and be a normal kid.

MI-Inconsistent: “Yes, there seems to be a discrepancy between your per- spective and Margo’s perspective on how to parent Benjamin. Your goals for Benjamin are for him to be a healthy, independent boy, yet your di er- ences of opinion on how to achieve that are keeping him from achieving those goals!”

ese provider utterances are MI-inconsistent. Both utterances begin with MI-consistent re ections of the di erence of opinion between the parents. however, the provider then assumes the expert role and draws connections between these di erences of opinion and the clients’ goals and values rather than eliciting from the clients how their disagreements might be related to their goals and values. e provider also blames the clients for their son’s problem by stating that their parenting behavior does not facilitate his being healthy and independent. Whether or not this provider observation is accurate, it is MI-inconsistent, because the provider is taking sides and thus is likely to elicit defensiveness and discord.

somewhat MI-Consistent: “You and Margo have some di erences of opin- ion in how to parent Benjamin, which seems natural. How should we work toward resolving those di erences?”

e provider statement is somewhat MI-consistent. It acknowledges the existing discrepancies between the parents’ perspectives and normalizes

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the situation. e provider then asks an open question, which invites the clients to share their perspectives. however, the speci c question asked focuses how to solve the problem, not exploring goals and values. us the provider has jumped to planning before evoking the clients’ motivations for change.

MI-Consistent: “You two are dedicated to Benjamin’s health. At the same time you have di erent perspectives on how best to help Benjamin. I wonder if we could take some time to discuss your goals for Benjamin. What are the goals each of you have for him and his future? [Waits for clients to respond]. How might these goals relate to your perspective on what is best for him in relation to helping him manage his diabetes?”

MI-Consistent: “You two are dedicated to Benjamin’s health. At the same time, you each have di erent opinions on how to best help him. Perhaps we can discuss some of your values as they relate to parenting. What are some of your values as a parent? [Waits for clients to respond]. How do these values relate to your approach to helping Benjamin manage his diabetes? How are these values similar and di erent from your partner’s in relation to helping Benjamin?”

is provider statement has several aspects that make it MI-consistent. e provider a rms that both parents are dedicated to the health of their son. Additionally, the provider highlights, in a non-judgmental way, the dis- crepancy between the parents. Next, the provider elicits from the clients their parenting values and how these values relate to their perspective on parenting the child.

Proposed Strategy 3: Decisional Balance

given that one or both parents may initially be at a precontemplative stage in relation to the need to learn parenting skills or change their parenting practices, it might be valuable to examine the pros and cons of participating in parent training. If both parents are involved in the discussion, it is important to elicit pros and cons from both parents. one approach is to encourage the parents to collaboratively develop the list of pros and cons. Another approach is to ask each parent to identify their individual pros and cons and facilitate a discussion between the parents.

Example: MI-Consistent/Inconsistent Decisional Balance

e following examples will illustrate MI-consistent and MI-inconsistent decisional balance for parents.

Client statement: “Margo tends to micromanage everything Benjamin does. It seems like he needs more space to be himself and be a normal kid.”

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MI-Inconsistent: “You feel Benjamin needs more space to become a nor- mal kid. On the one hand, I agree that there are bene ts to giving children space and letting them be ‘normal’. On the other hand, I can see Margo’s point that Benjamin may need structure from you to get his diabetes under control.

e provider responds with a re ection that captures only part of the dis- crepancy that exists—the father’s perspective. e provider then o ers his or her own unsolicited opinion about the pros and cons of the father’s per- spective rather than eliciting them from the clients. is may create the impression that the provider believes his or her opinion is more important than the clients and is likely to increase discord in the session.

somewhat MI-Consistent: “So the two of you have di erent perspectives on how to help Benjamin. Perhaps we can talk about some of the bene ts of learning new ways you can help manage his behavior and some of the draw- backs of not learning new skills to help him.”

e provider begins with a re ection that highlights the di erent perspec- tives of the parents. Further, the provider seems to be incorporating a deci- sional balance by eliciting the pro-change side of the argument. however, the provider makes no attempt to explore the drawbacks of changing and bene ts of not changing. us the provider has fallen into the taking sides trap. Additionally, within the context of two parents, the focus taken by the provider can be perceived as siding with one of the parents, which could elicit discord from the other parent.

MI-Consistent: “Both of you are concerned about Benjamin and his healthy development. You have di erent perspectives on how to best help Benjamin. Perhaps we can talk through some of these di erences by having each of you discuss the pros and cons of learning additional skills to help Benjamin improve his health. If it is okay with each of you, it might be helpful for us to discuss your perspective on the drawbacks of changing and not changing and the bene ts of changing and not changing your behavior.”

e provider demonstrates an MI-consistent approach in several ways. e provider begins by a rming the parents’ dedication to the health of their child. Further, the provider highlights that a discrepancy exists between the parents. e provider also reframes the discrepancy by sug- gesting both parents are trying to best help their son. e provider then facilitates the decisional balance by rst asking about the clients stay- ing the way they currently are. Next, the provider asks the clients about potential change e orts. one important point is that the provider empha- sizes the need for both parents to discuss their perspective. is avoids a potential perception that the provider is siding with one or the other parent. Finally, the provider avoids advocating for one side or the other (i.e., changing or staying the same) which is an important feature of a decisional balance.

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CLINICAL CHALLENGE 2: GROUPS

Description

ere is an increasing need for health and behavioral health providers to reach larger groups of people, including at-risk populations (Kazdin & Blaze, 2011; Prochaska & Norcross, 2010). An increasingly popular method to reach wider populations is to use groups (schneider Corey, Corey, & Corey, 2010). Using groups, whether to address mental health or medical issues, or facilitate self-help, allows providers to address common concerns among clients simultaneously, build o strengths and experiences of multiple clients, and facilitate mutual sup- port (Forsyth, 2011). When thinking of groups, you may envision people sitting in a circle talking about their inner-most secrets, or a 12-step group where some- one discusses his “rock bottom” and others discuss how they relate. groups take on many di erent formats ranging from process-focused groups, which empha- size personal exploration, to treatment groups for speci c problems (e.g., cogni- tive behavioral group for social anxiety), to educational groups such as a group for clients awaiting an organ transplant (Wagner & Ingersoll, 2013). given the increasing importance of groups to address a wide array of behavior and health issues, providers are o en in the position to facilitate a group. however, many may not have the necessary training or experience, especially to integrate MI into group work. Re ecting on our education and training as psychologists, we recognize that we encountered little to prepare us for group work.

our goal here is to discuss how you might use MI to address clinical chal- lenges encountered in group work. given the diverse applicability of MI, there has been a proliferation of MI in group work. For instance, MI groups have developed for at-risk adolescent alcohol and drug use (D’Amico, hunter, Miles, ewing, & osilla, 2013), promoting adherence to hIv medication (holstad, DiIorio, Kelley, Resnicow, & sharma, 2011), and reducing school truancy (ena & Da niou, 2009), to name a few. however, the concept of stand-alone MI groups to facilitate behavioral change is relatively new. More o en MI is inte- grated with other evidence-based change approaches like cognitive-behavioral therapy and the research support is limited (Wagner & Ingersoll, 2013). Because MI was developed with a focus on individual behavior change some aspects may be more di cult to adapt to groups. If you are interested in learning how to con- duct MI-based groups, we encourage you to read Motivational Interviewing in Groups by Wagner and Ingersoll (2013) where this topic is addressed more fully.

Whether you have facilitated groups or not, you can likely appreciate that working with a group of individuals is vastly di erent than working with a sin- gle individual. As such, there are unique challenges encountered when work- ing with groups. ese challenges range from having to simultaneously focus on the needs and goals of multiple individuals, to more complex factors such as interpersonal issues between group members and members being at di er- ent stages of engagement in the group. schneider Corey and colleagues (2010)

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outlined several challenges and problem behaviors that group leaders may face in facilitating a group. ese challenges, which will be the focus of our discus- sion, include intrapersonal concerns and interpersonal di culties in the group.

Intrapersonal Challenges

Individuals enter a group with their unique expectations, goals, and per- sonal characteristics that will impact their overt and covert group behavior. Internally clients may have concern about their referral to the group, worry about group involvement, di ering readiness to engage in a group and change, varying knowledge of the topic, and distinct apprehension about how they will relate to and be treated by other group members (schneider et al., 2010). e task for the group leader related to these challenges is how to address clients’ variability so that the group proceeds as a meaningful and valuable experience for all clients.

example: Kayla is a nurse practitioner. As part of her work in a trans- plant clinic, she facilitates an education group for individuals newly diag- nosed with liver disease. Because it is an educational group, she focuses on lecturing about liver disease and the transplant process. During a recent group, she noticed various responses from her clients in relation to the group. Tabitha focused on every word that Kayla said and took copious notes; however, she often seemed confused but never asked questions. Thomas did not seem to be paying attention. Jacob seemed to become increasingly anxious as she talked about the different topics. Stacy, a cli- ent who works as a pediatric nurse, acted as though she didn’t need to be at the group and was bored by it. Kayla was worried as she didn’t think the group members were interacting well with each other or learning the important information needed to help them manage their disease and treatment.

Kayla’s experience is o en encountered when facilitating groups, especially educational groups. What her experience highlights is the various intraper- sonal challenges that might in uence the development and functioning of the group. As discussed throughout this book, one of the values of MI is foster- ing engagement among clients. Young (2013) demonstrated how the spirit and principles of MI, discussed in chapter 2, align well with developing group cohesion and goals. Further, Rollnick, Miller, and Butler (2008) discuss some strategies that might be helpful for making educational groups more engag- ing. As educators we recognize how easy it can be to fall into lecture mode and try to be cognizant of how to remain MI-consistent when educating and facilitating group interactions inside or outside the classroom. here are some MI strategies that can be used to address some of the intrapersonal challenges in facilitating groups.

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Proposed Strategy 1: Evocative Questions

Using evocative questions in group work can help a provider engage group members, avoid the expert trap, and establish a group environment focused on understanding the unique needs of each group member. evocative questions are especially important for groups that have a speci c focus, such as education or a structured treatment for a particular disorder (e.g., exposure group for obsessive compulsive disorder). Using evocative questions can help establish the norm of open discussion in the group.

Example: MI-Consistent/Inconsistent Evoking

e following examples will illustrate MI-consistent and MI-inconsistent evoking for groups.

MI-Inconsistent: “Welcome to the living with liver disease group. How long have you had liver disease? Has anybody been to a group before? Who thinks this group will be helpful? Does anyone want to learn how improve their health?”

ese questions are MI-inconsistent because they are closed questions and are unlikely to facilitate clients opening up and engaging in discus- sion. Members of a group who are uncomfortable or uncertain about the group experience could easily respond with minimal answers. some of these questions also could have a judgmental quality to them and could increase discord and withdrawal from clients, which is the opposite of what MI-consistent providers would want. Also, asking closed question a er closed question could close o clients as the provider has succumbed to the question and answer trap.

somewhat MI-Consistent: “ ank you for coming to the living with liver dis- ease group. What are the di culties related to living with liver disease?”

is statement is somewhat MI-consistent in that the provider provides an a rmation for the group and asks an open question. however, the provider falls into the premature focus trap by asking about the problems associated with living with liver disease. In a group setting, this premature focus could lead to discord and reduced involvement among the group.

MI-Consistent: “ ank you for coming to the living with liver disease group. I’m sure some of you are unsure about this group—both what to expect and what is expected of you. at is natural. What are your expectations and concerns about this group?”

is statement is MI-consistent for several reasons. First, the provider a rms the clients attending the group by thanking them for coming and normalizes that clients have expectations and concerns about the group. Rather than asking a closed question or jumping into education, the provider asks an open question to elicit expectations and concerns from the clients. In doing so the provider expressed her desire to learn about the clients, value for open communication, and hope that clients are engaged in the group.

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Proposed Strategy 2: Discussing Pros and Cons of Group Work

group members will likely be at various stages of readiness to engage in group work and to make the types of changes the group is intended to facilitate. Many have di erent expectations and concerns about the group, as well as diverse knowledge and experience with groups. Discussing the pros and cons of group involvement can help clarify for both the provider and the clients what the unique expectations, hopes, and concerns of a particular group of clients may be. When working with groups, providers will likely encounter shared and dis- tinct pros and cons for each client. us, it is important for providers to ensure that each client has the opportunity to o er pros and cons, and this may require speci cally asking a client or two to share.

Example: MI-Consistent/Inconsistent Discussing of Pros and Cons

e following examples will illustrate MI-consistent and MI-inconsistent discussion of the pros and cons of group work.

Client 1 statement: “I am not sure that this group will help. All I need is a transplant!”

Client 2 statement: “I don’t know—I guess we could learn some things that may help.”

MI-Inconsistent: “It sounds like folks might have various perspectives about the value of this group. Let me take a little time now to tell you how this group can help each of you live better with your liver disease.”

e provider begins by highlighting the di erent perspectives expressed by group members using a re ection. however, rather than exploring the clients’ perspectives on the pros and cons of the group, the provider begins to o er her own opinion about the pros of the group. she has fallen into the expert trap with this response by implying that her perspective is more valuable or valid. By focusing only on the pros, she also fell into the trap of taking sides, which is likely to elicit anti-group responses from the clients.

somewhat MI-Consistent: “You all are probably concerned about what will best help you with your liver disease. If it is okay with you, I’d like to provide some information on why the transplant team thinks these groups are impor- tant for all transplant candidates. en I’d love to hear your perspectives at the end of the group.”

is statement is somewhat MI-consistent. e provider acknowledges that group members have ideas or concerns about how the group can be help- ful, which expresses empathy. she also introduces the option to address any questions or concerns at the end of group and asks permission to share information, both of which somewhat enhance a sense of collaboration. however, by tabling the discussion of client concerns to the end of the ses- sion and setting the agenda for the session without any client input, the provider is assuming the expert role. is may enhance disengagement and discord among those who are uncertain about the group.

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MI-Consistent: “You all are probably concerned about what will best help you with your liver disease. Also, each of you likely have di erent thoughts on how this group may or may not help you. at makes sense given that you are unique individuals and want what is best for you speci cally. Perhaps we can discuss each person’s thoughts about the drawbacks and bene ts of his or her own participation in the group. Tabitha, what are your thoughts about that?”

is provider statement is MI-consistent for several reasons. e provider acknowledged that the clients are seeking what is best for them, thereby con- veying a desire to collaborate with each group member. Next, the provider commented on the fact that each group member may have di erent opinions about the value of the group, normalizing these di erences and emphasizing autonomy. Finally, the provider facilitates the discussion by asking about the pros and cons of participation in the group from each member, thus avoiding taking sides or “defending” the group, and communicates a desire for open discussion that includes dissenting opinions among all members.

Proposed Strategy 3: Elicit-Provide-Elicit

Most groups will likely require a provider to give information about a disease/ disorder, speci cs of an o ense and legal issues, a treatment approach, group rules and norms, or any of a variety of other topics. e elicit-provide-elicit approach o ers an MI-consistent and engaging way to share information with group members. Using elicit-provide-elicit, a provider can also gain valuable insight into what the group already knows or doesn’t know about the topic through the initial eliciting. In contrast to how this strategy was discussed else- where in this book, in a group context a provider attends to all group members’ responses and ensures that all members had an opportunity to respond before and a er information is provided.

Example: MI-Consistent/Inconsistent Elicit-Provide-Elicit

e following examples will illustrate MI-consistent and MI-inconsistent elicit-provide-elicit in a group.

MI-Inconsistent: “Let’s begin today with talking about lifestyle changes in relation to liver disease. Many people think that all they need is medical treat- ment or a transplant to improve their health. However, there are many life- style changes you all can make that can help improve your liver disease. In fact, if you were to have a transplant there will be many behavior changes that will be required of you. We will talk about all of these today.”

is provider statement is MI-inconsistent and likely to elicit sustain talk—talk about not changing. e provider falls into the expert trap and essentially lectures the group. e provider does little eliciting to gain the clients’ understanding about liver disease or di erent changes that need to be made. similarly, there is no eliciting from the clients their reaction to the information the provider o ered.

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somewhat MI-Consistent: “ ere are a lot of di erent things that go into living with liver disease. Before we begin discussing these di erent things, I would like to learn what each of you already knows about managing liver disease. Who would like to discuss what they know about behavioral changes in relation to living with liver disease? [Waits for clients’ responses]. ank you for your information. e biggest changes that people can make are to stop drinking alcohol and take their medications. Does that make sense?”

is statement is somewhat MI-consistent for several reasons. e provider communicates empathy, acknowledging there are many things that require change, and uses elicit-provide-elicit. however, the provider prematurely focuses on making behavioral changes versus remaining less focused to learn what group members already know, which could result in missed information. Additionally, the provider asks who would like to share, a closed question, versus explicitly stating she would like to hear what each member knows. A er providing information, the provider asks a closed question that basically asks for agreement versus asking a question that is more likely to elicit client reactions to the information.

MI-Consistent: “ ere are a lot of di erent things that go into living with liver disease. Before we begin discussing these di erent things, I would like to learn what each you already know about managing liver disease. If it works for you we can go around and each of you can share what you already know or have heard about living with liver disease, because my bet is that each of you have information you already know that you can discuss. [Waits for clients to answer]. It sounds like you all have a lot of valuable information already. If I might add, one thing we might discuss is the di erent lifestyle changes, such as stopping drinking and eating healthier, that can help you better manage your liver disease. What are your thoughts about that?”

is statement is MI-consistent because the provider communicates empa- thy and that there is a lot of information about living with liver disease without talking about one speci c aspect, thus avoiding the premature focus trap. Additionally, before providing any information she elicits what is known currently by the group and emphasizes her desire to hear from group members. is communicates that the provider believes that each member has important information about the topic and that she values hearing from each of them. A er the client responses, the provider re ects and reinforces that the group knows a lot about the topic. she then announces that she would like to provide information, gives the information, and then elicits the group members’ reactions to the information.

Proposed Strategy 4: Group Planning

us far we have discussed planning as an MI-consistent strategy for working with individuals; however, as discussed earlier, there are many di erences in

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working with groups. one of those di erences is that group members may have di erent goals that they want to achieve. ese di erences may stall the prog- ress of the group or interfere with the accomplishment of more general goals. In chapter 3 we discussed MI-consistent planning. With some adaptations to account for multiple individuals, the planning process can be used to evoke from group members their individual reasons and goals for involvement in the group and then facilitate a discussion about developing group goals and outcomes.

Example: MI-Consistent/Inconsistent Group Planning

e following examples illustrate how a provider might use planning to help group members prepare to successfully participate in a group.

Client 1 statement: “I’m willing to try this group, but I’m not really sure about it.”

Client 2 statement: “Yeah, this seems like a hoop we need to jump through to get our transplant.”

Client 3 statement: “I don’t know—maybe there are things we can learn to make our lives better.”

MI-Inconsistent: “It sounds like some of you are uncertain about this group. You are probably more interested solely in a transplant. Part of the process for getting a transplant is to attend this group. Regular attendance is important even if you’re not sure about it. In this group we will discuss many things including the transplant process, taking medications and lifestyle changes before and a er the transplant. It is a lot of information but we will most likely cover something of interest to you.”

e provider starts with a re ection to acknowledge the di erent perspec- tives of the group members. however, her next few statements could be per- ceived as confrontational and could elicit discord from the group members who expressed concern about the group. Further, the provider is prescrib- ing the plan for the group, neglecting to elicit any expectations or goals from group members. e provider also assumes (instead of evoking from clients) that the group will meet their goals in some way. Telling the client what to do and assuming her plan will meet the various clients’ needs is not collaborative, and may diminish the clients’ sense of autonomy or invest- ment in the group.

somewhat MI-Consistent: “You all have di erent perspectives about this group. Before we move any further, perhaps we can take some time to discuss reasons for the group. [Waits for clients to respond]. ere are a variety of reasons for attending this group. So what should our plan of action be?”

is provider statement is somewhat MI-consistent. e provider begins with a re ection acknowledging that the group has di erent thoughts about the group and attempts to elicit reasons for the group from mem- bers. however, the provider does not explicitly elicit from each member of

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the group. Additionally, the provider attempts to elicit a plan but may miss important ideas from members with such a global question versus eliciting from each member.

MI-Consistent: “I am hearing that you all have di erent perspectives about how the group may or may not meet your needs. is seems natural to me as each of you knows what things tend to work best for you. Before we move any further, perhaps we can take some time to discuss your individual reasons for coming to the group. [Waits for clients to respond]. ere are certainly various important reasons for attending this group ranging from getting a transplant

Table 7.1. group Planning Form

Group Plan—Example
e most important individual reasons why we want to participate in group are:

1. so I can live better with liver disease 2. so I can get a transplant
3. so I can learn more about my disease 4. so my wife stops nagging me

Our group goals are to:

1. Better understand liver disease
2. learn about the transplant process
3. Better understand medication
4. Become more self-su cient in our disease
For group to be successful we must:
1. Attend meetings regularly
2. Respect each other’s opinions
3. openly discuss our opinions and reactions in group
4. Participate in all group learning activities
Some things that could interfere with group success include:
1. lack of participation of all members
2. Disrespect for di erences of opinion
3. Disinterest in some aspects of group
We can help each other be successful by:
1. Providing encouragement
2. Providing reminders about group goals
What we will do if we are not “sticking with” group the way we had hoped: 1. Remind each other why we are attending group
2. support each other
3. Remind each other of how the group has already helped

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to learning about lifestyle changes that can help you live with liver disease. Now that we know why each of you is attending the group maybe we can talk a bit about our collective plan for getting the most out of this group?”

is provider utterance is MI-consistent. It begins with a re ection acknowl- edging and validating the di erent opinions of group members. Next, the provider elicits the various reasons for attending the group, re ecting and reinforcing the various reasons. Finally, the provider introduces the idea of developing a group plan to make the group valuable for each client. is approach is validating and collaborative, and the plan developed will likely be more salient to the group members. As with the other strategies for working with groups, the provider attends to each group member to ensure that he or she is involved. You could also use the form in Table 7.1 to guide group planning. Rather than giving the form to each individual member, you could use the questions as a guide and present them using a dry erase board, blackboard, or ip chart. You could also elicit volunteers from the group to assume scribe duty and write the answers for the group on the board or chart.

Interpersonal Dif culties

A group consists of multiple individuals, each with their own histories, person- alities, idiosyncrasies, styles of communication, and pet peeves. us, inter- personal di culties seem natural and to be expected—sort of like sustain talk and discord. one role of a group facilitator is to build interpersonal cohesion and manage these di culties (Wagner & Ingersoll, 2013), and MI-consistent strategies may be particularly useful (Young, 2013). schneider Corey and col- leagues (2010) identi ed several “problem behaviors” that o en occur in groups that are presented in Table 7.2. some approaches to group facilitation suggest that you directly challenge these behaviors and encourage group members to do the same. e rst task in MI-consistent responding to these behaviors is to view them from an MI perspective as naturally occurring discord. Reframing them from problem behaviors to discord can be a signal that something needs to change in focus or discussion or interaction approach of the group. You can use of some of the proposed MI strategies for interpersonal di culties that follow to help manage some of these behaviors in group

example: John is a substance abuse treatment counselor who facilitates 12-member cognitive behavioral treatment groups at a community-based intensive outpatient substance abuse treatment program. In his current group, John has identi ed several clients that seem to be disrupting the group process. Steve is a very active participant, and John values his contributions and enthusiasm. However, Steve seems to monopolize a great deal of group time, leaving little time for other clients to share their thoughts and feelings. Additionally, Steve o en makes comments or asks questions that are not

182 MoTIvATIoNAl INTeRvIeWINg FoR ClINICAl ChAlleNges Table 7.2. group Problem Behaviors

Behavior

Description

Monopolizing

A group member taking up the majority of group time and talking about her or his concerns.

o -topic discussions

A group member routinely diverting the discussion away from the topic of discussion.

hostility

one group member responds in a passive or overtly aggressive fashion to another.

Acting superior

A group member may respond condescendingly or in a fashion that suggests he is better than the others.

socializing

group members engaging in side conversations or engaging the group in social discussions that are not group related.

Adapted from schneider Corey et al., 2010.

consistent with the topic John is trying to cover. Shari seems generally disen- gaged from the group, and John has observed her rolling her eyes or making sarcastic comments under her breath as other group members ask or respond to questions. It has become apparent that Shari believes she is not as ‘bad o ’ as the other group members and questions whether she can bene t from the group. Finally, Trisha, Bob, and Sarah frequently whisper and giggle among themselves, or pass notes to one another during group. John notes that those around them seem unsettled by their socializing during groups.”

Proposed Strategy 5: Shifting Focus

sometimes discord, such as that illustrated in this example, may be the result of the discussion topic. For some approaches to group therapy (e.g., process-oriented groups) challenging the discord is encouraged. however, that is MI-inconsistent. In MI, discord is an indicator of a need to change something. one strategy is to shi the focus away from what may be causing the discord. however, it is impor- tant to rst acknowledge the group member’s behavior and others’ responses before shi ing the focus to avoid communicating you are uncomfortable with what happened in the group and that group members can’t openly express them- selves. is approach can also be used if an individual is monopolizing group time to shi the focus of discussion away from the monopolizing member to others.

Example: MI-Consistent/Inconsistent Shi ing Focus

e following examples illustrate how a provider might use shi ing focus in an MI-consistent fashion to manage discord in a group.

Working with Multiple Individuals 183 Client statement: “I’m di erent than you all. I don’t use bad drugs, I just

drink alcohol.”

MI-Inconsistent: “Let’s not talk about whose drug use is better or worse. Let’s discuss how our drug has a ected our lives.”

is provider utterance is MI-inconsistent, because the provider dis- misses the concern communicated by the client in relation to the group and adopts an expert role. e provider’s response is also likely to raise more discord as it could be perceived as challenging. e response has the potential to make the client more passive rather than more active in the group.

somewhat MI-Consistent: “ anks for sharing. In what ways has drug and alcohol use a ected your lives?”

is statement is somewhat MI-consistent as the provider acknowledges the client statement in a non-confrontational way and shi s focus. however, the provider avoids acknowledging the discord statement from the client, which may invalidate the client’s concerns and communicate that dissenting opin- ions are not valued in the group. e result of this statement is that the client could disengage from the group and become less motivated to change.

MI-Consistent: “You are concerned about the di erent types of substances used by the group members. We may be getting a bit ahead of ourselves in discussing the drugs used, and I wonder if we could talk about what each of you is hoping to gain from this group.”

e provider begins by using a re ection to acknowledging the client’s con- cern but doesn’t agree or disagree with it. e provider then shi s the focus of the discussion away from the di erences in drugs used to a discussion about what each member wants from the group. is could also transition into a discussion about group rules and norms.

Proposed Strategy 6: Re ective Listening

Re ective listening is at the heart of MI and can be used at any time in an MI-consistent interaction. In groups, re ective listening can serve multiple purposes (Wagner & Ingersol, 2013). First, the group leader can use re ective listening to respond to interpersonal di culties. By responding re ectively the provider models alternate ways group members can respond to others in the group. second, the provider can facilitate group members responding to each other using re ective listening.

Example: MI-Consistent/Inconsistent Re ective Listening

e following examples illustrate how a provider might use re ecting to manage interpersonal di culties in a group.

184 MoTIvATIoNAl INTeRvIeWINg FoR ClINICAl ChAlleNges Client statement: “I’m di erent than you all. I don’t use bad drugs, I just

drink alcohol.”

MI-Inconsistent: “ is is a common misconception—alcohol is also a drug.”

is statement is not a re ection and is MI-inconsistent. e information the provider gives is accurate, but it is a direct confrontation of the client’s statement. is could facilitate expressions of resentment or hostility from other group members who feel put down by the client’s statement.

somewhat MI-Consistent: “You only use alcohol.”

is statement is a re ection and is somewhat MI-consistent. e pro- vider validates the concern of the client and resists the righting re ex. however, this simple re ection is unlikely to move the conversation for- ward in a useful direction. us, although not wrong, with this response the provider is missing an opportunity to engage other group members, elicit more about the client’s concerns and discord, or shi the focus to a topic that is more likely to facilitate change.

MI-Consistent: “You’re not convinced you belong in this group because you use only alcohol.”

is provider re ects the client’s disagreement about their involvement in the group, which is MI-consistent. however, the provider does not indicate that he agrees or disagrees with the statement or directly confront the cli- ent’s belief. he simply communicates that the provider is hearing what the client has communicated. Choosing to re ect this particular aspect of what the client has said is also likely to help shi the discussion to fruitful topics such as the di erent treatment needs and goals of each group member.

MI-Consistent: “I hear what you are saying about your involvement in the group. At the same time I wonder what others in the group are hearing you say. Perhaps each of you can re ect back what you have heard. [Waits for each member to respond]. ank you for your responses. Maybe you can re ect back to the group what you heard in their various responses.”

e provider’s response is MI-consistent as he is attempting to facilitate a discussion using re ective listening. e provider acknowledges hearing the client. Next he prompts the other group members to re ect back what they hear in the client’s statement. e provider a rms the members for their responses and invites the client to re ect back to the group what he has heard.

Proposed Strategy 7: Eliciting Group Member Strengths

ere can be a tendency when clients in a group experience interpersonal di – culties with one or more other members to focus on others’ negatives. Providers can attempt to minimize interpersonal di culties by eliciting strengths and positive assets from group members who are having di culties.

Working with Multiple Individuals 185

Example: MI-Consistent/Inconsistent Eliciting of Group Member Strengths

e following examples will illustrate MI-consistent and MI-inconsistent eliciting of group member strengths.

Client statement: “I’m di erent than you all. I don’t use bad drugs, I just drink alcohol.”

Client 2 Response: “Who are you to talk? Your situation is worse than each of us!”

MI-Inconsistent: “Okay, I’m going to jump in here as this is not appropriate group behavior according to our rules.”

is is statement is a common one in facilitating groups with the goal of reminding members how to participate in the group and to keep the discus- sion from escalating. however, the provider is assuming an expert role and is also judgmental by labeling the behavior as inappropriate. Although in some groups this might be a suitable response, especially to reinforce group rules and behavior, it is MI-inconsistent.

somewhat MI-Consistent: “You two seem to be heading in a direction that is concerning to me. If it’s okay with you, let’s step back for a moment and talk a bit about what strengths we see in each other.”

is provider statement is somewhat MI-consistent as it is not as con- frontational as the rst statement and the provider expresses his concern. however, the provider interrupts the discussion without asking permis- sion. e provider only shares his perception of the situation and does not elicit the perceptions of other group members. Finally, the provider includes other group members in the discussion of positive qualities, making the situation solely about the two group members.

MI-Consistent: “If it’s all right with the group I would like to jump in for a minute. You two seem to be heading in a direction that is concerning to me and I wonder how others feel about it. [Waits for others to respond]. I wonder if we can step back for a moment and talk a bit about what strengths we see in each other and how that helps the group meet our goals.”

is provider statement is MI-consistent for several reasons. First, the pro- vider asks permission to jump in to the discussion versus interrupting. e provider then shares his perception of the situation and asks for the per- ceptions of others in the group. Finally, the provider elicits from the group to comment on the strengths of each member and also how each member helps the group move forward.

CHAPTER SUMMARY

In this chapter we presented the clinical challenges of using MI with multiple individuals. Working with multiple individuals presents unique challenges for

Table 7.3. summary of Motivational Interviewing strategies for Clinical Challenges Related to Multiple Individuals

Clinical Challenge

Suggested MI Strategies

Parents:

Di erences between parents in relation to problem de nition, motivation for change, and ideas for change

giving information: Providing information in an engaging and objective fashion about the nature of the child’s behavior and the relationship between parenting and child behavior change.

exploring goals/values: elicit from parents their parenting goals, values, and goals for the child and contrast them with parenting behavior.

Decisional balance: Facilitate decision making among parents by eliciting pros and cons about changing from both parents with the goal of developing shared motivation to change.

Intrapersonal challenges in groups:

Individual factors and behaviors that may slow the development and progression of the group.

evocative questions: Using questions aimed at genuinely understanding the client’s concerns, motivations, and understanding about the group to engage each member in the group.

exploring pros/cons of group work: engage participants in a discussion about the bene ts and drawbacks of the group to address di erences in readiness to change, motivations, and concerns about the group.

elicit-provide-elicit: Before providing information,
elicit from all members what they already know about
a topic and elicit reaction to the information from all members a er providing it. is can be used to reconcile di erences among group members.

group planning: engaging the group in determining shared goals and methods to reach those goals within the group. It is important to develop some consensus among group members.

Interpersonal challenges in groups:

Behaviors displayed by or between group members that a ect the cohesion and functioning of the group.

shi ing focus: Acknowledging the discord in the group and shi ing focus to a less discord-evoking topic.

Re ective listening: Use of re ection to highlight the meaning in group members’ comments either by commenting or eliciting re ections from group members.

eliciting strengths: Asking group members to comment on the positive attributes and strengths of other members with the goal to reduce discord.

Working with Multiple Individuals 187

using MI as di erent people may have di erent levels of motivation, reasons for changing or not, and perspectives of the concern/problem. erefore, we empha- sized throughout the chapter the importance of attending to these factors for all individuals involved in the session and demonstrated how you may achieve this with parents and groups using di erent MI strategies. While we did not speci cally discuss MI groups, we invited you to envision how MI can be used to address intra- and interpersonal di culties you may encounter when work- ing with groups of people. In particular we encouraged you to be cognizant of applying MI strategies to the entire group versus one or two individuals. Many of the strategies we proposed can help you remain MI consistent while including multiple individuals and their perspectives. Table 7.3 summarizes the clinical challenges and suggested MI strategies.

8

Challenges in Learning to Use and Implement MI

As discussed in chapter 1, MI is not easy to learn. Most of the strategies and concepts presented in this book sound deceptively straightforward and intuitive. In fact, MI-consistent strategies are counterintuitive for many we have trained, especially in the situations in which they would be most useful (e.g., when cli- ents are angry or upset, have limited motivation to change, or disagree with the provider). In this chapter we provide a number of tips that we have found use- ful in our own development as MI providers, applied in the MI trainings we have provided, and learned as MI researchers. rough these various experi- ences with MI we have learned valuable information from our trainees, clients, and participants that has solidi ed our appreciation for the nuances of learning MI. In many ways, our process has paralleled how Dr. William Miller developed his appreciation and understanding of MI (Adams & Madson, 2006). us, we o er these tips for your consideration as you begin to develop or strengthen your utilization of MI. As part of this discussion we also focus in greater detail on two challenges in learning to use MI: provider feelings of frustration and provider personal experiences that are similar to client experiences.

TIP 1: SET REALISTIC EXPECTATIONS

Many providers and students enter MI training with unrealistic expectations about the ease with which they will learn MI. is is probably based in part on the fact that many providers believe the practices they implement with clients are actually far more MI-consistent than they actually are (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). Whatever the source of the unrealistic expecta- tions, they can result in disappointment and frustration during and following MI training.

Miller and Moyers (2006) observed that there eight separate tasks or stages involved in learning to successfully implement MI: (1) relinquishing the expert role and opening oneself to truly collaborating with clients; (2) developing skill

learning to Use and Implement MI 189

in client-centered counseling, including accurate empathy; (3) recognizing and selectively re ecting change talk; (4) eliciting and increasing change talk; (5) man- aging discord; (6) engaging in MI-consistent change planning; (7) consolidating client commitment; and (8) integrating MI with other intervention styles. For some providers, particularly those with training in methods of psychological counseling or psychotherapy, the spirit of MI and the client-centered counsel- ing aspects of MI may come relatively easy. In contrast, the more advanced and less familiar aspects of MI, such as recognizing and reinforcing change talk as well as eliciting and strengthening change talk, may come much less naturally. For providers from disciplines with training, practices, and philosophies that are less compatible with MI, all aspects of learning MI may present more of a chal- lenge (schumacher, Madson, & Nilsen, 2014). As noted in chapter 1, for many providers (including mental health providers), intensive workshop training fol- lowed by ve sessions of coaching may be insu cient for expert competence or even beginning pro ciency in MI to be obtained (Madson, schumacher, Noble, & Bonnell, 2013; Miller et al., 2004; Moyers et al., 2008; schumacher, Williams, Burke, epler, & simon, 2013; smith et al., 2012). In fact, for many, learning pro- cient use of MI parallels the process (e.g., practice, observation and coaching) many providers undertook to learn how to practice in their disciplines.

We strongly recommend that providers and students set expectations that match the amount of MI training they will receive. Based on experience, if a pro- vider is able to receive workshop training, plus up to 20 feedback-based coaching sessions, it seems highly likely that he or she will achieve expert competence in MI (schumacher et al., 2013). If a provider, like many providers we train, does not have the time or resources to undertake that amount of training, he or she may still learn some valuable practices and principles of MI that can enhance work with clients. If a provider has not received any formal training in MI, but would still like to gure out how to apply at least some of the practices and prin- ciples of MI to his or her daily work, this book was written with that provider in mind. Although a novice provider is unlikely to be able to conduct a motivational interview a er reading this book, he or she should be able to implement select strategies that may help better address common clinical challenges. however, remember the value and importance of the MI spirit that we emphasized throughout this book. Without adhering to the spirit of MI in implementing these strategies, they will likely be implemented in an MI-inconsistent fashion.

TIP 2: BE OPEN-MINDED

Many providers come to our MI training with very strong pre-existing beliefs about what types of strategies are best for a particular type of cli- ent (schumacher et al., 2014). For example, many years ago, a fellow trainer shared the story of a provider who had said of MI, “this stu probably works for some clients, but some clients just need to be confronted.” As elaborated later in this chapter, it has been our experience that in fact the clients who

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are viewed as most appropriate for MI are o en those who need it the least and vice versa. other providers may draw seemingly premature conclusions about whether or not MI “works” on the basis of one or two attempts at using MI (o en attempts that are not particularly MI-consistent). What we always encourage is that if a provider is considering adopting MI, he or she must keep an open mind. MI is not a panacea, that is, it will not be the solution for every client who is struggling with issues of motivation. But MI is also quite di er- ent from practice as usual (Miller & Rollnick, 2009), and is something that few providers (except those with extensive training in MI) just naturally imple- ment in their day-to-day conversations with clients. We remember our early sessions attempting to implement MI. In the beginning we were uncertain about whether MI worked, because our implementation of the practices and principles was not yet expert. however, we also remember the rst sessions when we really “got it” and clients seemed to almost miraculously move from just considering change (contemplation) or even not considering change at all (precontemplation) to fully committed to change and ready to act on a change plan (Prochaska & DiClemente, 1983). If providers are considering adopting MI (or select MI strategies), we encourage them to try it with their most chal- lenging clients, the ones they are certain will only respond to confrontation. We also encourage them to try it repeatedly (not just once or twice) before drawing conclusions about whether or not it is a style that they would like to make part of their repertoires. We think it is important to remember the advice of Dr. William Miller—“learn the same way I did, from your clients” (Adams & Madson, 2006 p. 104).

TIP 3: GET OBJECTIVE FEEDBACK

As noted, individuals who are attempting to learn MI are generally not very good at gauging how MI-consistent their work is. Although in general, providers tend to overestimate how MI-consistent their performance is (Miller et al., 2004) we have also observed, especially among more self-critical trainees, an underesti- mation of how well they are performing. It is hard to imagine how a provider could improve their performance in implementing MI-consistent strategies, if he or she did not know how well they were currently implementing the strategies. us, getting objective feedback is generally recommended for anyone who is hoping to learn to implement MI (e.g., Miller et al., 2004). It has been our experi- ence that providers perceive great bene ts of receiving objective feedback and are very reluctant to submit work samples or allow observation of their practice so they can receive objective feedback. Interestingly, as we have conducted research to improve how we do MI training, one option we considered was not requiring work samples. We noted, as had many others, that providers were very reluctant to comply with requests to provide work samples for coaching (e.g., schumacher, Madson, & Norquist, 2011; schumacher et al., 2012). To test this assumption, we informally surveyed providers we had trained about the perceived value of

learning to Use and Implement MI 191

getting feedback on work samples. Much to our surprise, even among groups of trainees who had shown great reluctance to submit work samples for feedback, responses were uniformly supportive of this practice.

Motivational Interviewing Trainer Tips

set realistic expectations Be open-minded
get objective feedback

TRAINING CHALLENGE 1: CLIENTS WHO FRUSTRATE YOU

Description

In MI training we deliver to providers who are already in practice (i.e., not stu- dents), those who attend the trainings will o en describe de-identi ed examples of clients they see. e clients that providers discuss most frequently are those with whom they have a long-standing relationship. sometimes they will discuss long-standing positive relationships with clients. ese relationships are gener- ally characterized by the client attending all appointments, following the provid- er’s guidance, and speaking positively about their experience with the provider. In our experience, these cases are o en discussed as examples of either (1) how the provider has already successfully used MI to motivate change in the past, or (2) a client for whom the provider believes MI would “work.” Closer examination of the rst case o en reveals that the client was highly motivated for change at the outset of his or her interactions with the provider, and it was this intrinsic motivation that helped foster a long-standing positive relationship rather than MI. Remember, MI is not practice as usual and it is highly unlikely that a pro- vider without training in MI is actually practicing MI (Miller & Rollnick, 2009). Closer examination of the second case o en reveals that the client who is per- ceived as the “perfect MI client” actually does not need MI at all; he or she has su cient intrinsic motivation to implement provider recommendations and/or develop and follow through on his or her own plan for change without MI.

More commonly, providers who attend our trainings will discuss clients with whom they (and sometimes the entire sta at a facility) have a long-standing negative relationship. From their perspective, the water that has passed under the bridge in these long-standing relationships is littered with missed appoint- ments, requests for special treatment, non-compliance with recommendations, disruptive behavior, and so on. ese clients are o en presented as a chal- lenge to the MI system—clients who cannot possibly bene t from MI and for whom a more confrontational, directive, and possibly even punitive approach

 

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is necessary. Although MI is not a panacea (Miller & Rollnick, 2009) and is not a guaranteed solution to every problem with every client, closer evaluation of these cases o en reveals a pattern of provider-client interactions that may serve to entrench rather than reduce discord and sustain talk (Moyers, Miller & hendrickson, 2005). From the client perspective, the water under the bridge in these long-standing negative relationships is o en littered with lack of under- standing, improper treatment (long wait times, insu cient time with a provider, rude sta ), unsolicited advice, confrontation, and/or direct orders. Whatever the cause, long-standing negative client-provider relationships seem to be a source of signi cant frustration to providers. e following example illustrates a case in which a long-standing relationship may elicit frustration from a provider.

example: Bob is diagnosed with a serious mental illness and has been a client at a community mental health center on and o for approximately 20 years. Over those 20 years the sta has seen Bob cycle through “good periods” when he takes his medications and attends other services such as counseling and vocational rehabilitation, and “bad periods” when he does not take his med- ication or follow other recommendations. During these “bad periods” Bob o en ends up homeless or in jail. ese bad periods are o en very dishearten- ing and frustrating to providers. It is also frustrating to providers that when Bob returns to the community mental health center for services a er one of these “bad periods” he does not openly discuss what they perceive as the cen- tral cause of his recent misfortune—his lack of compliance with treatment. Instead he complains that his case manager is never available to drive him to doctor’s appointments or to help him get his bene ts check.

Providers we train and work with also describe encounters with clients who seem to enter the client-provider relationship with a “chip on their shoulder.” ese clients may perceive that they have been mistreated (by the facility at which they are seeking service, their family, the criminal justice system, life cir- cumstances, other providers, etc.), believe that the interventions o ered are not appropriate or su cient for their speci c needs, or have other issues that lead to immediate or almost-immediate discord between client and provider. is can be very frustrating to providers who enter the relationship with optimism and a sincere desire to help. ( e unique challenges presented by clients who have been forced to participate in an intervention are addressed further in chapter 4). I (Js) vividly recall an occasion when another provider’s client came to the reception area of my o ce stating that he had a question about his medication and was told I was the person to ask. Being a psychologist (who doesn’t prescribe), I wasn’t sure how I could be helpful, but knew that the young man had misconceptions about my role in his treatment that needed to be clari ed. As soon as we had found a con dential location to discuss his concerns, I was immediately accosted with very loudly voiced accusations that I had withheld medication from him. By using the spirit and strategies of MI, I was able to de-escalate and clarify the situation and, most importantly, avoid feeling frustrated or intimidated by

learning to Use and Implement MI 193

this client. e following example illustrates a client with whom a provider may experience immediate frustration.

example: A er an hour in the waiting room, Rachel is called back to the exam area for her prenatal visit. A er a nurse takes her vital signs and walks her to an exam room, she refuses to enter the room, stating, “You are just going to make me wait here again. I know I’m not a doctor, and I know this is a free clinic, but my time is valuable and I deserve some respect.” A er the nurse nally convinces Rachel to enter the exam room and have a seat on the exam table, Rachel proceeds to answer the nurse’s questions about her health since the last visit with curt and hostile sounding replies.

Proposed Strategy 1: Af rmation List

As described in chapter 2, during an MI session a rmations are used primarily to help clients see their strengths, resources, and previous successes from which a change e ort may build. however, in our years of providing training to various audiences, we have come to identify another potential use for a rmations—to help providers see clients’ strengths, resources, and previous successes, thereby reducing their frustration. In frustrating interactions with clients, whether the relationship is long-standing or brand new, we have observed that many pro- viders seem to make what social psychologists have termed the “fundamental attribution error” (Ross, 1977). e fundamental attribution error describes the tendency of people to underestimate the impact of situational factors on others’ behavior and to overestimate the impact of dispositional factors. We infer that many providers may make this error in thinking about the clients who frustrate them, because of what they tell us about those clients: “he just doesn’t want to change,” “you just can’t talk to people like that,” “she came in with a chip on her shoulder.” It could also be inferred from what they fail to mention to us about the client or his or her situation: “she has had to wait at least an hour in the waiting room for every visit,” “his medications cause terrible side e ects,” or “he has had 12 di erent case managers assigned to him over the last 20 years.”

e foundational spirit of MI, as noted in chapter 2, requires not only evoca- tion (of change talk), but also collaboration, acceptance, and compassion. us feelings of frustration and the negative thoughts about a client that likely accom- pany those feelings are impediments to MI practice. To help those we train, coach, and supervise overcome this common barrier to MI practice, we have found helpful to rst ask them to list at least ve (and ideally more) strengths or accomplishments that describe this client before discussing MI-consistent strat- egies that might be used. By focusing on the characteristics or accomplishments of a client that are worthy of a rming, provider perspectives of a client o en shi and they are better able to be collaborative, accepting, and compassionate. In turn this spirit of collaboration, acceptance, and compassion better allows

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providers to see the role that situational factors (sometimes including the pro- vider’s own behavior!) may have played in eliciting non-adherence, complaints, or hostility from the client. With this fresh perspective, providers are o en able to more e ectively identify and apply other MI strategies to help clients move toward positive change.

Example: MI-Consistent/Inconsistent A rmation List

e following examples will illustrate how to identify when you are frus- trated with a client (like Bob or Rachel) and might bene t from developing an a rmation list, as well as how the list might look. You will notice that these examples di er from many of the other examples in this book as they do not represent sample dialogue between a provider and a client. Rather, they represent examples of what a provider might say to themselves or to another provider about a client.

MI-Inconsistent: “Bob needs to take responsibility for his own mental health. He is in complete denial about his mental illness. He comes in here with such a strong sense of entitlement; he thinks case managers are like personal assistants.”

MI-Inconsistent: “Rachel is a hostile person. She has no right to treat people that way and if she’s not careful she’s going to cross the line and get kicked out of this clinic. What does she expect from a free clinic, anyway?”

is type of thinking about a client—a list of weaknesses, liabilities, and de cits—does not foster MI spirit and makes it very hard for a provider to apply other MI strategies that might promote change.

somewhat MI-Consistent: “We need to nd someone to take Bob to pick up his bene ts check.”

somewhat MI Consistent: “Rachel struggles with long wait times.”

e rst example illustrates a provider thinking about a client in a way that shows compassion and a desire to help. however, it also suggests the pro- vider is thinking of the client as a passive recipient of services who needs sta to “do” for him, rather than an autonomous person capable of col- laborating in his own care. e second example illustrates a provider who is thinking about a client in a somewhat but not fully empathic and sup- portive fashion.

MI-Consistent: “Bob has really shown perseverance. Despite the ups and downs of the past 20 years, he keeps coming back and trying to make changes in his life. He has also been very patient with us—I know these case management changes have been confusing and frustrating to him. He also knows a lot of what he needs to get back to health and stability, regular medical care, regular income, and so on.”

MI-Consistent: “You’ve got to admire Rachel’s dedication to her baby. She doesn’t come from a social circle that really supports the importance of prena- tal care, and the wait times people experience when they receive services here would try anyone’s patience—and yet she keeps coming back.”

learning to Use and Implement MI 195

is type of thinking about a client or creating a list of strengths and accom- plishments fosters MI spirit and makes it much easier for a provider to apply other MI strategies in a manner that will help promote positive change.

TRAINING CHALLENGE 2: CLIENTS LIKE YOU Description

If you’ve lost 10 pounds, does that make you an expert on weight loss? What if you’ve lost 50 pounds? What about 100 pounds? If you used to have an alcohol use disorder and have been sober for 20 years, does that make you an expert on recovery? If you were a youth o ender and turned your life around, does that make you an expert on o ender rehabilitation? From an MI perspective, the answer would be: yes—sort of. it makes you an expert on how you success- fully lost weight, stopped drinking, or turned your life around. And, if you are a weight loss counselor, an addiction counselor, or work in the juvenile justice system, there will undoubtedly be clients who will bene t from the wisdom of your personal experience. however, there will also undoubtedly be clients whose best strategy for weight loss, sobriety, or rehabilitation looks almost nothing like the strategy you successfully used to achieve those goals. In order to be MI-consistent in your approach to helping others, it is important to remember that in each interaction with a client there are two experts in the room: the client is an expert on his or her situation, values, preferences, etc. and the provider is an expert on how others (including possibly the provider himself) have successfully achieved changes in their lives (Miller & Rollnick, 2002).

our experience in providing MI training is that many undergraduate stu- dents, graduate students, and professionals of all types are inclined to assume that the strategies that have worked for them will work for others. is is true in “real play” exercises in which participants in our trainings partner-up and take turns discussing changes they are considering and practicing MI skills. e changes discussed in these real play exercises are o en typical, everyday changes that most people have tried to make; things like reorganizing a closet, starting an exercise program, or watching less television. It is quite common, especially during early practice exercises, for us to overhear comments such as, “have you tried [strategy]? It worked for me!” Participants o en nd themselves drawing on their personal experience to advise their partner rather than sticking to the use of MI skills.

We also observe this tendency in role-play exercises, case discussions, and supervision sessions based on actual or role-played interactions with a client who is considering a bigger life change, such as abstaining from alcohol use a er years of heavy drinking or better managing their blood sugar to get control of their diabetes. We have observed that providers who had successfully made the change being considered by their client o en favored sharing the strategies that had worked for them rather than eliciting from the client the strategies that he or she believes might work best. Providers who had similar experiences also at

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times seemed to assume that the client’s underlying motivations, hesitations, and so on were identical to the provider’s. For example, during a case discus- sion, a provider presenting a client who repeatedly expressed the belief that sub- stance abuse treatment was not the right place for him, because he was not as bad the other clients, might say, “I was just like him. I thought I was so di erent than everyone else. he just needs to get past that.” Miller, sorensen, selzer, and Brigham (2006) note that there is evidence that substance abuse treatment pro- viders who are in recovery may be less open to varied perspectives on substance abuse treatment, and the same may be true for providers in other areas who have overcome the same problems their clients are facing.

To combat what seems to be a fairly common tendency to assume that having had a similar personal experience gives us a unique understanding of the per- sonal experience of our clients, we recommend using empathic listening strate- gies, particularly re ections and open questions. When beginning to implement MI, it may be most important to intentionally use these strategies when you are most certain that you understand the client’s perspective. is will create oppor- tunities to see rsthand that sometimes your assumptions are accurate and other times they are not. In cases where you lack certainty, checking your assumptions will likely come more naturally to you, and you probably won’t have to be as intentional about it.

Proposed Strategy 1: Re ective Listening

In teaching the concept of re ective listening in MI, Miller and Rollnick (2013) o en refer to omas gordon’s (1970) model of communication. In this model, communication involves three processes: encoding, hearing, and decoding. encoding is the process whereby the speaker identi es what he or she wishes to express and chooses words through wish to express it. hearing, as you might guess, is the process whereby the listener perceives the words uttered by the speaker. Decoding is the process by which the listener infers the speaker’s mean- ing from the words he or she has heard. As Miller and Rollnick (2013) note, there are three places where communication can go awry: (1) the speaker may not clearly state what it was he or she hoped to express; (2) the listener may not clearly hear what the speaker said; or (3) the listener may mistake what the speaker meant by what he or she said.

Quick Reference
How Communication Can Go Wrong

speaker doesn’t say what he or she means. listener doesn’t accurately hear what speaker said. listener misinterprets what speaker meant.

 

learning to Use and Implement MI 197

From an MI perspective, re ective listening is about con rming that what a listener thinks the speaker meant is what he or she actually meant. us re ec- tive listening, when well done, can be very useful to help ensure that our assump- tions about the ways in which our clients might be similar or di erent from us are accurate.

Table 8.1 is an example of how we presented this model of communication in a recent training session. As you review Table 8.1, imagine what would have happened if Mike had gone with his assumptions about what I (Js) meant, rather than using a re ection to check those assumptions. If he assumed I thought he was angry, he might have wondered what he had done that would have made me think he was angry. is in turn might have caused him to feel worried or irritated. If he assumed I heard his stomach growl, then he might have felt self- conscious and embarrassed. Worst of all, if he hadn’t clari ed what I meant, I might have missed the opportunity to try my rst deep-fried tamale (if you’re ever in the Mississippi Delta, I highly recommend it).

Example: MI-Consistent/Inconsistent Re ective Listening

e following examples will illustrate how to use re ective listening to ensure you aren’t making assumptions about a client because he or she seems similar to you.

Client statement: “I admit I have problems, but I don’t need substance abuse treatment. Everyone here is way worse than me.”

MI-Inconsistent: “Do you think you are di erent than everyone else here?” Although this question seeks to clarify what the client meant, it is not a

re ection and it is not MI-consistent. Closed questions such are o en Table 8.1. Communication Model example

encoding error

Julie inks: “I wonder if Mike wants to grab lunch during the break.”

Julie says: “Are you angry?” (Instead of, “Are you hungry?”)

Mike Re ects: “You think I’m angry with you.”

hearing error

Julie says: “Are you hungry?”

Mike hears: “Are you angry?”

Mike Re ects: “You think I’m angry with you.”

Decoding error

Mike hears: “Are you hungry?”

Mike inks: “oh no, she must have heard my stomach growl.”

Mike Re ects: “You heard my stomach growl.”

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perceived (and intended) as very confrontational, and thus are likely to result in defensive responding from the client (Miller & Rollnick, 2013).

somewhat MI-Consistent: “You don’t need substance abuse treatment.”

is statement is somewhat MI-consistent. e simple re ection expresses empathy, but is likely to result in either a simple yes or no response or encourage sustain talk.

MI-Consistent: “You think you are di erent than everyone else here.”

is statement is MI-consistent because it seeks to clarify what the client meant by his or her statement. e client is likely to respond by either cor- recting the provider if that is not what he or she meant or further exploring the ways in which he or she is di erent from and perhaps similar to the other clients in the treatment program.

Proposed Strategy 2: Open Questions

open questions are another great way to test assumptions you may have about a client. When it comes to testing your preconceptions about a client, o en the most important open question to ask is the one of which you feel certain of the answer. A classic example of this is in the Miller and Rollnick (1998) Motivational Interviewing: Professional Training Series videos. In one of the case examples in this series, John, who was referred from his employer subsequent to a positive drug screen, notes that if he had kids he might have to rethink his drug use. To this, Dr. William R. Miller responds, “And why would you do that?” seems like an obvious, almost senseless question. everyone knows that it isn’t good for parents to use drugs, right? But drawing on the communication model, the MI provider is always aware that he or she might be surprised (perhaps very surprised) by the answer. John might have said, “Drugs cost money, and if I had kids I’d need to spend the money on the kids.” or he might have revealed, “I’ve had two prior arrests for drug possession, the next time I get caught, I’m going to prison for sure. You just can’t do that to kids.” or he might have said, “My parents were heavy drug users and it really messed me up.” or he might have said any number of other things. By asking John an open question, Dr. Miller not only creates an opportunity for John to voice his own reasons for change (a central goal in MI), but also creates an opportunity to test any assumptions he might have about John’s reasons for change based on his own experience as a parent or the experience of countless clients with whom he has worked over the years. Dr. Miller also avoids the potential discord that can result from errone- ous assumptions. For example, if Dr. Miller had assumed that John’s objection to parental drug use was a moral one (e.g., “everyone knows parents shouldn’t use drugs”) when in fact it was a practical one (e.g., “I think it is ne for parents to smoke marijuana, the problem is that it’s illegal in this state, and I don’t want my kids to su er from the legal consequences.”), John would likely have felt judged and discord would have emerged.

learning to Use and Implement MI 199

Example: MI-Consistent/Inconsistent Open Questions

e following examples will illustrate how to use open questions to ensure you aren’t making assumptions about a client because he or she seems simi- lar to you.

Client statement: “I admit I have problems, but I don’t need substance abuse treatment. Everyone here is way worse than me.”

MI-Inconsistent: “Do you think you are di erent than everyone else here?”

is question is not an open question, it is a closed question. It is also MI-inconsistent because it is like to be perceived by the client (and possibly be intended by the provider) as a direct confrontation of the client’s asser- tion that he doesn’t need treatment. is is likely to increase discord in the interaction.

somewhat MI-Consistent: “In what ways are others worse than you?”

is open question is somewhat MI-consistent in that it invites the client to elaborate. however, it invites the client to elaborate on why others are worse than the client. is is sustain talk and is unlikely to help the client move toward change on the problems he or she does have.

MI-Consistent: “So you have problems, but you aren’t sure this is the right place for you. Tell me a little more about the types of problems you have had.”

MI-Consistent: “So you aren’t certain this is the right place for you to solve your problems. What would be helpful to you?”

ese provider utterances are MI-consistent. Both begin with a re ection of the client’s uncertainty about treatment. is is likely to reduce discord. en the provider uses open questions to gather more information about the client’s perspective. In the rst example, the provider seeks to gain a bet- ter understanding of why the client perceives substance use as a problem. In the second example, the provider seeks to gain a better understanding of what type of treatment or assistance (if any) the client perceives he or she needs to overcome the problem. Although the questions will give the pro- vider very di erent information, both are likely to help the provider gain a better understanding of this client’s unique perspective.

SUMMARY

In this chapter we provide tips for learning and implementing MI-consistent practices in your daily work. We have found those who set realistic expecta- tions, keep an open mind about the role of MI in their work, and get objective feedback about their use of MI have the most positive training outcomes and enjoyable training experience. We have also found two situations, summarized in Table 8.2, that impede implementation of MI for many providers. e rst is clients with whom a provider feels frustrated. Intentionally focusing on the strengths, achievements, and positive qualities of these clients seems to help

200 MoTIvATIoNAl INTeRvIeWINg FoR ClINICAl ChAlleNges Table 8.2. summary of Training Challenges

Training Challenge

Suggested MI Strategies

Clients who frustrate you.

A rmation lists: Developing lists of the positive qualities and strengths of clients to shi focus away from perceived de cits.

Clients who are like you.

Re ective listening: Use of re ection to better understand and appreciate the meaning of the client’s comments and experience.

open questions: Using open questions aimed at genuinely understanding the client’s concerns, motivations, and understanding.

providers adopt the spirit of MI in their interactions with them. e second impediment is a temptation to draw more heavily on the provider’s personal wisdom and experience than the client’s wisdom and experience when work- ing with clients who are similar to the provider. very intentional use of re ec- tive listening and open questions may increase collaboration and support of autonomy in these situations. We believe that the practices and principles of MI are within everyone’s grasp. With practice and appropriate training, you can achieve whatever level of expertise you believe is appropriate for your practice.

CONCLUSIONS

We hope you have enjoyed reading Fundamentals of Motivational Interviewing: Tips and Strategies for Addressing Common Clinical Challenges. We also hope that this book has provided food for thought on how the principles and practices of MI might be applied to a variety of ubiquitous, but nonetheless frustrating, clini- cal challenges. MI is a powerful communication style that can facilitate positive change in even the most seemingly hopeless situations. We have observed this phenomenon directly in clients we have treated and participants in our research studies. We have heard this feedback from providers we have trained and also experienced the bene ts of MI rsthand. We both look forward to opportunities to participate in, as well as facilitate practice exercises, during the training we provide. at is because, depending on the particular exercise, participation pro- vides opportunities for us to discuss a change we are considering in our own lives with a training participant who seeks to (1) empathically and collaboratively re ect or evoke our desire, ability, reasons, need, and commitment to change; and/or (2) a rm our strengths and past successes; and/or (3) help us develop a realistic and personalized plan for change. ose opportunities, in turn, provide a vehicle through which we develop or renew our motivation for changes in our own lives—from organizing a closet or le cabinet to healthy eating and regular exercise.

learning to Use and Implement MI 201

As noted in chapter 1, the body of research on MI is growing at an incred- ible pace (lundahl & Burke, 2009). Moreover, this research indicates that almost invariably when MI is applied to clients experiencing a particular problem or challenge, it helps facilitate positive change—and in many cases with a smaller dose of an intervention (Burke, Arkowitz, & Menchola, 2003; hettema, steele, & Miller, 2005; lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Rubak, sandbaek, lauritzen, & Christensen, 2005). however, it is also important to note, that for many problems and challenges to which MI is applied, the research support is still emerging. In those areas, we believe that MI is best applied as an adjunct to approaches with a longer track record and stronger evidence base rather than a stand-alone intervention. is book is designed to support this adjunctive use of MI. In the course of practice-as-usual, a provider may apply the relevant MI concepts, principles, and strategies described in this book as needed to help overcome hurdles introduced by less readiness to change, loss of momen- tum, psychiatric symptoms, and working with multiple individuals. To do this, however, we remind you of the importance of the MI spirit as a foundation for the integration of MI with practice as usual! In fact, our discussions of MI-consistent and MI-inconsistent applications of strategies o en emphasized the importance of the MI spirit in guiding the application of a particular strategy. Based on our experience training others in MI we cannot over state this point.

In 1983, Dr. William R. Miller introduced an approach to helping clients achieve positive life changes that can best be described as revolutionary. is approach was elaborated by Dr. Miller and Dr. steve Rollnick in 1991 with the publication of the rst edition of the Motivational Interviewing text. since that time, MI has been re ned, studied, and practiced by countless others. We are excited to be a part of this ongoing revolution and invite you, our reader, to see for yourself how collaboration, evocation, acceptance, and compassion can help your clients overcome the most di cult challenges they face on the path to posi- tive life changes. Whether this book is the beginning of your development as a MI-consistent provider or an addition to your MI library our hope is that we have contributed to your understanding of MI and its application to challenges faced in helping others change.

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ABOUT THE AUTHORS

Julie A. Schumacher, PhD, is an Associate Professor and Vice Chair for Professional Education and Faculty Development in the Department of Psychiatry at the University of Mississippi Medical Center and Director of the Mississippi Psychology Training Consortium. She is actively involved in motiva- tional interviewing practice, training, supervision, dissemination, and research and has received multiple NIH grants for her work in this area.

Michael B. Madson, PhD, is an Associate Professor in the Department of Psychology at the University of Southern Mississippi. He is actively involved in training, supervising, and researching motivational interviewing as part of health and harm reduction interventions. His work has been funded by multiple agencies, including the NIH and the American Psychological Foundation.

Page numbers followed by “f” and “t” indicate gures and tables.

Ability, 35–36, 50–51
Absolute worth, acceptance and, 19 Abstinence violation e ect, 107 Acceptance, 19–21, 146
Accurate empathy, 19
Action, transtheoretical model and, 12, 71 Activating, mobilizing statements

and, 37
Activities, lack of interest in, 136–140 Adherence, 80–81. See also

Non-adherent clients Adolescents, 4

Advice, 5 A rmations

acceptance and, 20–21 depression and, 131–132 engagement and, 44
frustrating clients and, 193–195 overview of, 27–28

Agendas, handouts and, 135 Agenda setting, focusing and, 46,

47–48t Aggression, 167

Alcohol prevention, 61, 65–67t Ambitions. See Expectations, overly

ambitious Ambivalence

decisional balance and, 53 non-adherence and, 82 push-back and, 22

Ampli ed re ections, 31 Angry clients, 192

Anxiety
e ectiveness in treating, 4 non-adherence and, 82 overview of strategies for, 164t

Anxiety, trauma-related, and obsessive compulsive disorders. See also Post-traumatic stress disorder

assessment feedback and, 143–145, 145t

description of, 140–142 empathetic listening and, 142–143 emphasizing personal control and,

148–149
envisioning and, 150–153 evocation and, 145–146 importance and con dence and,

102–103
o ering choices and, 146–148 planning and, 149–150
social anxiety, 141–143

Appointment policies, 76
Approval, a rmations vs., 27 Assessment feedback, 143–145, 145t Autonomy

acceptance and, 19–20
clients involved in legal system and,

92–94
non-adherence and, 88–89 no-shows and, 78–80
slow progress and, 100, 105–106

Avoidance, anxiety disorders and, 140, 141–142

INDEX

216 INdEx

BASICS. See Brief Alcohol Screening and Intervention for College Students

Behavioral therapy, motivational interviewing vs., 14t

Brief Alcohol Screening and Intervention for College Students (BASICS), 61, 65–67t

Building motivation for change, 42

CAT acronym, 37
Challenging clients. See Frustrating

clients; Obstacles to learning motivational interviewing; Similar clients

Change plans. See also Planning depression and, 134, 136 development of, 57–58t, 57–59 non-adherence and, 86–88
slow progress and, 100, 104–105

Change Plan Worksheets, 57–58t, 59, 150, 151t

Change talk
eliciting and responding to, 38 evoking and, 50
importance of, 29
overview of, 35–37
slow progress and, 100

Choices, o ering, 146–148
Cigarette smoking, 4, 138t
Client autonomy. See Respect for client

autonomy
Client-centered therapy, motivational

interviewing vs., 13–14 Clients, de ned, 9

Closed questions, 25–26 Coaching, 190–191
Coaching sessions, 6, 189 Cognitive dissonance, 11 Cognitive therapy, motivational

interviewing vs., 14t Collaboration, overview of, 16–17 Collecting summaries, 32–33 Commitment, mobilizing statements

and, 37 Communication, model of,

196–197, 197t Compassion, 21–22

Complex re ections, 30–31 Compliance, adherence vs., 80–81 Components of motivational

interviewing, overview of, 16 Concentration di culties, 132–136 Concerns, asking permission to

provide, 118–120
Con dence, 102–104, 109–111 Con dence rulers. See Scaling questions Consolidating commitment to

change, 42
Contemplation, transtheoretical model

and, 12, 71
Control, personal. See Respect for

client autonomy
Corrections, use of MI for, 4 Courts. See Legal system Criminal justice system. See Legal

system

dARN talk, 35–36, 50–51. See also Ability; desire; Need; Reason

decisional balances
depression and, 134, 136, 138t lapses and relapses and, 112–113 motivational interviewing vs., 13 overview of, 53
parents and, 171–172

decoding, 196–197 de nitions. See Terminology depression

a rming and, 131–132 description of, 125
di culty concentrating and,

132–136
envisioning and, 130–131 evidence for e ectiveness in

treating, 4
feelings of worthlessness or guilt

and, 129–132
handouts and, 134–136, 137t, 138t hopelessness and, 125–129 hypothetical questions and, 126–127 lack of interest in activities and,

136–140
looking back and, 139–140 overview of strategies for, 163t

Index

planning and, 128–130

summarizing and, 133–134 desire, 35, 50
diabetes control, 4
discord

clients involved in legal system and, 94–96

groups and, 182

overview of, 39–40 disengagement, signs of, 43 double-sided re ections, 30–31

Eating disorders, 4 E ectiveness of motivational

interviewing, overview of, 3 Elicit-provide-elicit approach

groups and, 177–178
lapses and relapses and, 108–109 overly ambitious expectations and,

121–122 overview of, 55

Emotional well-being, 4 Empathetic listening, 142–143 Empathy, accurate, 19 Empowering clients, 24–25 Encoding, 196–197
Engaging

BASICS example and, 65t
HUB City Steps example and, 62t indications of successful, 45 overview of, 42–45
road map and, 60t

Envisioning, 130–131, 150–153 Evoking

anxiety, trauma-related, and obsessive compulsive disorders and, 145–146

BASICS example and, 66t
groups and, 175
HUB City Steps example and, 63t indications of successful, 53 non-adherence and, 82–83
overly ambitious expectations and,

120–121
overview of, 17–18, 49–53 road map and, 60t

217

slow progress and, 101–102 Exchanging information, 54–55. See

also Giving information Expectations, overly ambitious

asking permission to provide a concern and, 118–120

description of, 116–118 elicit-provide-elicit and, 121–122 overview of, 123t
training and, 188–189
using evocative questions and,

120–121
Exposure-based interventions,

140–141

Family Check-up, 168 Feedback. See also Assessment

feedback
agenda setting and, 47–48t, 49 anxiety, trauma-related, and

obsessive compulsive disorders

and, 143–145, 145t parents and, 168–170 training and, 190–191

First impressions, 42 Focusing

BASICS example and, 66t
groups and, 182–183
HUB City Steps example and, 62t indications of successful, 49 overview of, 45–49, 46t, 47–48t psychotic symptoms and, 160–161 road map and, 60t

Foundational spirit, overview of, 16–22 Four processes of motivational

interviewing. See Processes of

motivational interviewing Frustrating clients, 191–195, 200t Fundamental attribution error, 193

Giving information
clients involved in legal system and,

90–92
lapses and relapses and, 108–109 no-shows and, 75–77
overly ambitious expectations and,

118–120

218 INdEx

Giving information (cont.)
parents and, 168–170
planning and, 54–55
psychotic symptoms and, 154–156

Goals, 44, 170–171. See also Expectations, overly ambitious

Gordon, omas, 196
Group Planning form, 180t
Groups. See also Multiple individuals

description of, 173–174
discussing pros and cons of working

with, 176–177
eliciting group member strengths

and, 184–185 elicit-provide-elicit approach and,

177–178
evocative therapy and, 175 intrapersonal challenges and,

174–181
intrapersonal di culties and,

181–185
overview of strategies for, 4, 186t planning and, 178–181, 180t re ective listening and, 183–184 shi ing focus and, 182–183

Guiding principles, overview of, 22–25

Guilt, 129–132

Handouts, depression and, 134–136 HBA1c, 4. See also diabetes control Health promotion, 59–61, 62–64t Hearing, communication and,

196–197
High school counseling, 4
HIV risk behaviors, 4 Hopelessness, 125–129. See also

depression Hostility, 182t

HUB City Steps, 49, 59–61, 62–64t Hypertension, 59–61, 62–64t Hypothetical questions, 126–127

Importance, 102–104, 109–111 Importance-Con dence Scale, 51. See

also Scaling questions

Importance rulers. See Scaling questions

Individuality, groups and, 174–181 In ection, re ections and, 28 Information exchange, 54–55. See also

Giving information
Initiating discord. See discord Initiating rolling with resistance, 95 Interest, lack of, 136–140 Intrapersonal challenges, 174–181,

186t
Intrapersonal di culties, 181–185,

186t

“Know Your Numbers” cards, 47–48t, 49

Lapses and relapses
decisional balance and, 112–113 description of, 107–108
eliciting and a rming strengths

and, 113–114
giving information and, 108–109 looking back and, 111–112 overview of, 123t
reassessing importance and

con dence, 109–111 reframing and, 114–115

Learning. See Training
Legal system, clients involved in

autonomy and, 92–94 description of, 89–90
giving information and, 90–92 initiating discord and, 94–96 overview of, 97t

Less ready to change clients
involved in legal system, 89–96, 97t non-adherence, 80–89, 97t no-shows, 72–80, 79t, 97t
overview of, 71–72, 96–98, 97t

Linking summaries, 33–34 Listening to clients, 24. See also

Empathetic listening; Re ective

listening
Looking back, 111–112, 139–140 Looking forward, 85–86

Index

Loss of momentum
lapses and relapses, 107–115 overly ambitious expectations,

116–122
overview of, 99, 122, 123t slow progress, 100–106

Maintenance, transtheoretical model and, 12, 71

Mental illnesses, 4, 124–125, 165. See also Anxiety, trauma-related, and obsessive compulsive disorders; depression; Psychotic symptoms

Menus of options non-adherence and, 86–88 planning and, 56–57, 56f

Meta-analyses, 3–4
Miller, William R., 3, 198, 201 Misconceptions about motivational

interviewing, 12–15, 14t
Missed appointments. See No-shows Mobilizing change talk/statements, 37 Momentum. See Loss of momentum Monopolizing, 182, 182t
Motivation

change talk and, 35, 50 non-adherence and, 83 understanding, 24, 83

Motivational Interviewing in Groups

(Wagner and Ingersoll), 173

Motivational Interviewing: Professional Training Series videos (Miller and Rollnick), 198

Multiple individuals
groups, 173–185
overview of, 166, 185–187, 186t parents, 166–172

National Comorbidity Survey Replication, 124

Need, 36, 51
Negative relationships, 191–195 New Year’s Resolutions, 107 Non-adherent clients

description of, 80–82

219

emphasizing autonomy and, 88–89 evocative questions and, 82–83 looking forward and, 85–86 overview of, 97t

revising change plan, discussing options and, 86–88

scaling questions and, 83–85 No-shows

description of, 72–73
emphasizing autonomy and, 78–80 giving information and, 75–77 motivational interviewing-consistent

referrals and, 73–75 overview of, 97t planning and, 77–78, 79t

OARS acronym, 25. See also A rmations; Open questions; Re ections; Summaries

Objectivity, clients involved in legal system and, 91–92

Obsessive-compulsive disorder. See Anxiety, trauma-related, and obsessive compulsive disorders

Obstacles to learning motivational interviewing, overview of, 8

O -topic discussions, 182t Open-mindedness, 189–190 Open questions

complex, 161
engagement and, 44, 45
overview of, 25–27 preconceptions about clients and,

198–199 Options

non-adherence and, 86–88 planning and, 56–57, 56f

Parents
decisional balance and, 171–172 description of, 166–168 exploring goals and values and,

170–171
overview of strategies for, 186t providing feedback and information

and, 168–170

220 INdEx

Parent training programs, 167 Permission, asking for, 118–120,

156–157
Person-centered therapy, 11, 14t Planning. See also Change plans

anxiety, trauma-related, and obsessive compulsive disorders and, 149–150

BASICS example and, 66–67t depression and, 128–130 groups and, 178–181, 180t HUB City Steps example and,

63–64t
indications of successful, 59 no-shows and, 77–78, 79t overview of, 54–59, 56f, 57–58t road map and, 60–61t
slow progress and, 100

Post-traumatic stress disorder (PTSd), 144, 145t

Praise, a rmations vs., 27 Precontemplation,transtheoretical

model and 12, 71
Preparation, transtheoretical model

and 12, 71
Preparatory change talk, overview of,

35–36
Problem behaviors, groups and, 181,

182t
Processes of motivational interviewing

alcohol prevention example, 61, 65–67t

engaging, 42–45
evoking, 49–53
focusing, 45–49, 46t, 47–48t health promotion example, 59–61,

62–64t
overview of, 42
planning, 54–59, 56f, 57–58t road map for, 59, 60–61t

Process-focused groups, 173. See also Groups

Project Match, 59
Pros and cons, 176–177. See also

decisional balances Providers, de ned, 9

Psychological illnesses. See Anxiety, trauma-related, and obsessive compulsive disorders; Mental illness; Psychotic symptoms

Psychological well-being. See Emotional well-being

Psychosis, de ned, 153 Psychotherapy, motivational

interviewing vs., 13–14, 14t Psychotic symptoms

asking permission and, 156–157 description of, 153–154
giving information and, 154–156 overview of strategies for, 164–165t re ective listening and, 158–160 shi ing focus and, 160–161 stacked questions and, 161–162 summarizing and, 157–158

Question and answer trap, 25 Questioning. See Closed questions;

Open questions
Quick xes. See Expectations, overly

ambitious

Reactance theory, 88
Readiness rulers. See also Scaling

questions
depression and, 134, 135–136, 137t overview of, 51–52

Readiness to change, 12, 71. See also Less ready to change clients

Reason, 36, 51
Recycling, 99
Referrals, no-shows and, 73–75 Re ecting change talk, 38
Re ections, 28–31, 44. See also Complex

re ections; Simple re ections Re ective listening

clients like you and, 196–198 groups and, 183–184
no-shows and, 78
psychotic symptoms and, 158–160,

165t
Reframing, lapses and relapses and,

114–115

Index

Relapse, 99. See also Lapses and relapses

Relational component of motivational interviewing, 16

Resentful clients, 192 Resistance. See also discord

as a prior term for discord, 94–95 Respect for client autonomy

acceptance and, 19–20 anxiety, trauma-related, and

obsessive compulsive disorders

and, 148–149
clients involved in legal system and,

92–94
non-adherence and, 88–89 no-shows and, 78–80
slow progress and, 100

Reverse psychology, motivational interviewing vs., 13

Reviews, overview of, 3–4 Righting re ex

compassion and, 21 de ned, 22
depression and, 126 non-adherence and, 81 resisting, 22–24

Road map for motivational interviewing, 59, 60–61t

Rogers, Carl, 11, 16
Rolling with resistance, 95 Rollnick, Steve, 201
RULE acronym, 22
Rulers. See Scaling questions

Scaling questions. See also Readiness rulers

depression and, 127 non-adherence and, 83–85 overview of, 51–52

Schizophrenia, 154. See also Psychotic symptoms.

Schools, 4
Self-e cacy, 11
Shi ing focus, 160–161, 182–183 Similar clients, 195–199, 200t
Simple re ections, overview of, 29–30

221

Skills, basic a rmations, 27–28 open questions, 25–27 re ections, 28–31 summaries, 31–34

Slow progress
assessing importance and con dence

and, 102–104
description of, 100–101 emphasizing personal control and,

105–106
evocative questions and, 101–102 overview of, 123t
revising change plan and, 104–105

Smoking cessation, 4, 138t
Social anxiety, 141–143 Socializing, groups and, 182t
Spirit of motivational interviewing,

overview of, 16–22
Stacked questions, 161–162 Strengths, eliciting and a rming,

113–114, 184–185 Summaries

depression and, 133–134 engagement and, 44
overview of, 31–34
psychotic symptoms and, 157–158

Summarizing change talk, 38 Superiority, 182t
Sustain talk, 38–39, 52–53

Taking steps, mobilizing statements and, 37

Technical component of motivational interviewing, 16

Techniques, motivational interviewing vs., 13

Terminology
de nitions of motivational

interviewing, 11–12
lapses and relapses and, 114–115 of mental illnesses, 124 overview of, 9, 11

Tone, re ections and, 28 Training

clients like you and, 195–199

222 INdEx

Training (cont.)
frustrating clients and, 191–195 objective feedback and, 190–191 open-mindedness and, 189–190 overview of challenges in, 5–6,

188–189
setting realistic expectations and,

188–189
Transition summaries, 34 Transtheoretical model (TTM), 12, 71 Trauma. See Anxiety, trauma-related,

and obsessive compulsive disorders; Post-traumatic stress disorder

Treatment groups, 173. See also Groups Trickery, motivational interviewing

vs., 13
TTM. See Transtheoretical model Two-phase approach to motivational

interviewing, 42 Unfairness, 192

Values, 44, 170–171

Work samples, 190–191 Workshops, 5–6, 189 Worthlessness, feelings of, 129–132

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