3. The Motivational Interviewing Framework

Motivational Interviewing Framework

Motivational Interviewing is underpinned by a spirit and principles.

Motivational Interviewing includes microskills, change talk skills and commitment talk skills.

These all work together to bring about change.

 

 

 

 

 

The Spirit

Embodying the Spirit of Motivational Interviewing is essential.

Autonomy:

     Honours the person’s choices

Collaboration:

    Guides rather than directs

Evocation:

    Actively encourages change talk, focusing on person’s own motivation for change.

“In the 11 years since the first edition of (the Motivational Interviewing book), we have found ourselves placing less emphasis on techniques of motivational interviewing and ever greater emphasis on the fundamental spirit that underlies it.” (Miller and Rollnick, 2002.)

  • Motivation to change comes from the person, and should not imposed from ‘outside’;
  • It is the person's task, not the counsellor's, to articulate and resolve their ambivalence;
  • Direct persuasion is not an effective method for resolving ambivalence ;
  • The style is generally a quiet and eliciting one;
  • The counsellor is directive in helping a person to examine and resolve ambivalence;
  • The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

               (Source: “What is Motivational Interviewing?” Rollnick and Miller, 1995).

Honoring autonomy

MI also requires a certain degree of detachment from outcomes—not an absence of caring, but rather an acceptance that people can and do make choices about the course of their lives. Clinicians may inform, advise, even warn, but ultimately it is the client who decides what to do. To recognize and honor this autonomy is also a key element in facilitating behavior change. There is something in human nature that resists being coerced and told what to do. Ironically, it is acknowledging the other's right and freedom not to change that sometimes makes change possible.

Collaborative

MI rests on a cooperative and collaborative partnership between client and clinician. Whereas the client-centered clinical method is a broad approach to the consultation, MI addresses the specific situation in which patient behavior change is needed. Instead of an uneven power relationship in which the expert clinician directs the passive patient in what to do, there is an active collaborative conversation and joint decision-making process. This is particularly vital in health behavior change, because ultimately it is only the client who can enact such change.

Evocative

Often health care seems to involve giving client what they lack, be it medication, knowledge, insight, or skills. MI instead seeks to evoke from client that which they already have, to activate their own motivation and resources for change. A client may not be motivated to do what you want him or her to, but each person has personal goals, values, aspirations, and dreams. Part of the art of MI is connecting health behavior change with what your patients care about, with their own values and concerns. This can be done only by under-standing patients' own perspectives,by evoking their own good reasons and arguments for change.       

Adapted from:
Motivational Interviewing in Health Care pp6-7,
Stephen Rollnick, William R. Miller, Christopher C Butler, Guildford Press, 2008.

 

 

Principles

Principles of Motivational Interviewing

1. Express empathy:

Acceptance facilitates change.
Skillful reflection is fundamental.
Ambivalence is normal.

2. Develop discrepancy

A conflict between present behaviour and important goals or personal beliefs can motivate change.
Highlighting the potential contradictions can increase ambivalence.
Encourage person to present arguments for change.

3. Avoid argument

Arguments are counterproductive.
Defending breeds defensiveness.
Resistance is a signal to change strategies.
Labeling is unnecessary for change.

4. Roll with resistance

Momentum can be used to good advantage.
Perceptions can be shifted.
New perspectives are invited but not imposed.

5. Support self-efficacy

The belief in the possibility of change is an important motivator.
The person is responsible for choosing and carrying out personal change.


 

 

Microskills: OARS

Reflective listening is one of the most fundamental skills to develop for client-centred counselling in general and for Motivational Interviewing in particular.

There are three other core communication skills that are important in engaging and throughout the process of Motivational Interviewing asking open questions, affirming and summarising.

Together these four skills in English form the mnemonic acronym: OARS

  • Asking Open questions
  • Affirming
  • Reflecting
  • Summarising

Reflective Listening

Reflective listening is a critical skill involved with engagement, for reducing discord, minimising sustain talk and increasing change talk.

Levels of reflection:

      Simple Reflections

      Add little or nothing to what person has said; repeat or slight rephrase

    Complex Reflections

    Make a guess about meaning that has not been directly stated; paraphrase, metaphor, reflection of feeling, etc

    Amplified reflection

    Double-sided reflection

Asking Open questions

  • Open the door, encourage client to talk
  • Try to avoid 3 questions in a row
  • Offer 2 reflections per question asked
  • Think engagement rather than “fact finding” as initial task.

Affirming

  • Appreciate a strength or positive action
  • Should be true and genuine
  • Express positive regard and caring
  • Strengthen working alliance
  • Diminish defensiveness
Examples of Affirmations:
  • Commenting positively on an attribute
    • It takes a lot of strength to talk about change
  • A statement of appreciation
    • I appreciate your making the effort to come here today
  • A compliment
    • I like the way you have thought this through
  • An expression of hope, caring or support
    • I can see this is a difficult decision for you and I appreciate how honest you are being

Summarising

Collect material that has been offered, e.g.

    So far you’be told me

Link content with something discussed earlier e.g.

    That sounds a bit like what you told me about feeling lonely sometimes

Transition to a new task e.g.

    Let me summarise what you’ve told me so far and see if I have missed something important….


 

Change talk (DARN)

Change talk is any self-expressed language that is an argument for change.

There are four types of speech acts that are change talk:

  • Desire
  • Ability
  • Reason
  • Need

Together these four types of talk in English form the mnemonic acronym: DARN

Desire: Want, Wish, Like

  • How would you like for things to be different?
  • What are you looking for from this program?
  • How do you want your life to be different a year from now?
  • What do you wish for?

Ability: Can, Could, Able

  • If you did decide to change, how could you do it?
  • What do you think you might be able to do?
  • How confident are you that you could ..... if you made up your mind?
  • How likely are you to be able to .....?

Reason: Specific reasons why. If.... then...

  • What are some of the reasons for making a change to ….?
  • What’s the downside of how things are now?
  • What would make it worth your while to ….?
  • What might be the three best reasons for …?

Need: Express an urgency for change

  • What needs to happen?
  • How important is it for you to make a change to ....?
  • How serious or urgent does this feel to you?

 

Commitment talk (CATs)

Change talk is is pre-paratory change talk.

Commitment talk signals movement towards the resolution of the ambivalence in favour of change.

There are three types of commitment talk:

  • Commitment
  • Activation
  • Taking steps

Together these three types of talk in English form the mnemonic acronym: CAT

Commitment (intention, decision, promise)

Commitment language signals the likelihood of action

  • I want to
  • I could
  • I have good reasons to
  • I need to

Activation (willing, ready, preparing)

Activation language signals the person is learning in the direction of the action.

  • I am willing to...
  • I am ready to....
  • I am prepared to ...

Taking Steps

aking steps is a form of speech indicating that the person has already done something in the direction of the change:

  • I bought some running shoes so I can exercise
  • This week I didn't snack in the evening.
  • I called three places about possible jobs.