Introduction to Motivational Interviewing

So what I'll be going over is kind of what this model is, its kind of theoretical overview, and pretty much how to, to use it. So learning objectives is looking at the role of motivational interviewing and helping people change. Whenever you see the acronym MI, or the short form, that's going to be motivational interviewing if you're not familiar. And then I'll go over the basic the basic tools and principles and processes of this. So the focus of this presentation will be on helping people make an initial commitment to change. In this trans-theoretical model provides a template for looking where— looking at where someone might be in the process of change. So we can look at pre-contemplation, where someone is not thinking about change at all. If you ask them about change, they'll say no. Contemplation is they're saying, well, maybe I'm going to think about it. And then preparation would be they're actually doing the things. So motivational interviewing is designed to bring someone from a no to a maybe, or especially a maybe to doing. And it really works in that kind of realm where somebody might be starting to think about change, but it actually helps facilitate the actual action of building their motivation to take steps and to make some changes. So as I was saying before, the therapeutic relationship is something that is very much underappreciated in counseling. We often hear people talking about the technique that you're using— are you using cognitive behavioral therapy, dialectical behavioral therapy, or some other approach— and we're focused particularly on techniques and models, but the If you look at that pie graph, it really accounts for 15% of change according to the research here. And the therapeutic relationship is that 30% chunk there. And what that is is the quality of that relationship accounts for so much of the change. And yet, it's something that's often kind of undervalued in favor of looking at specific technique. And now, this is a technique. ACT, the MI, is a technique. But it's a technique designed to enhance that therapeutic relationship and really what, what accounts for a big chunk of change. The other ones there you see are expectancy factors. So there's a placebo effect. If they expect it's going to help, then it will. And there is a 40%, which is extratherapeutic events like the living situation, other life events outside of the therapeutic relationship that account for a big chunk of change. So what we're focusing on is how to really enhance and maximize that relationship to facilitate the change process. So motivational interviewing is, I guess, metaphorically, a lot more like a dance than a wrestling match. Now, when we think about getting someone to change, it's like, I want to make them change. You just want to get in there and just wrestle them to the ground. And I'm going to tell them how it is. And I have all of the techniques and the best advice. But it doesn't really work that way. And so it's more like a dance that you do with someone in collaboration with that person. And we'll kind of get more into that. But this is kind of the metaphorical arrangement here. If you don't like this metaphor, here's another one. So it's the finger trap. You know, you pull harder and it gets tighter. This metaphor is from Acceptance and Commitment Therapy. Used to look at fighting with your unhelpful thoughts. Like if you have an unhelpful thought, like, you know, I'm not enough, and you're like, I can't think that, I can't think that, then you're going to think that more because you're focusing on it. You get in that kind of relationship with it. This metaphor applies to motivational interviewing because when someone resists change and you want to fight that resistance with more resistance, say, no, you have to do this, and they say, no, I'm not going to, you're tightening the, the, the relationship, you have less flexibility to actually work with that person, um, and, and you can't even move as it's tightened. So leaning in, going into resistance, rolling with resistance is really what this approach is going to, to focus on. When someone's looking at, uh, at change, when they're thinking about change, they come with a lot of reasons not to change and a lot of reasons to change, and they're often kind of right in the middle there. And motivational seesaw, which you can call ambivalence. And so people don't present in one way where they're kind of all this or all that. They're kind of complex systems where they can want two things at the same time, often at very high levels. And so they could really want to change and really be stuck in this, this, this pattern at the same time. And to recognize that people present with ambivalence, uh, And when someone presents this way, it is so tempting to go in and just strike away their reasons not to change, become the superhero, and then kind of stomp on their reasons and tell them, these are your reasons to change because X, Y, Z. You should do it because of this. And we really want to just give them those reasons. And when we do that, again, that is that resistance dynamic that it gets further facilitated. It's more frustration for both people. And so this approach is fundamentally humanistic. It's based in the work of Carl Rogers, and he says this, uh, here: In my early professional years, I was asking the question, how can I treat or cure or change this person? Now I would rephrase the question in this way: How can I provide a relationship which this person may use for his own personal growth? So it's coming out of a fixing mentality and into a kind of a way of being mentality, very person-centered. And, and, um, Thomas Gordon came up with all these conversational roadblocks. He was a peer of Carl Rogers, this humanistic approach, and he comes up with this list of conversational roadblocks. And so one of them is ordering. You know, you have to do X, Y, and Z. If you hear the word have to or something like that, you know, it's one of these roadblocks. Warning, if you don't do this, then something bad's gonna happen. And we see this on like cigarette packages, you know, especially in Canada where they're increasingly like taking over the whole package. It's just warning, warning, and If somebody presents with heightened risks using alcohol, for example, you say, well, if you don't stop, your liver— that's one of these kind of conversational roadblocks. Moralizing. What you really should do. So these should statements that people often use to beat themselves over the head with, often components of shame, these should statements further facilitate a sense of shame often. And persons struggling with addiction or change are often already feeling that quite a bit and are often quite isolated. So these types of statements just kind of add more weight to an already heavy situation. Advising. So, why don't you, have you ever thought of, you know, we get all, think of this when you have a headache or something and someone's like, have you ever thought of, you know, Tylenol, you know, the one with the caffeine. And they just give you unsolicited advice. You're like, yeah, I know. Like, and so that's kind of what you— have you ever tried this? Unsolicited. Using logic. Well, you would think logic is useful, but, you know, again, with those cigarette packages, the facts are, you know, 25% of people who X, Y, and Z. And so we're emotional beings fundamentally, and the facts often are not persuasive enough in this way to change our behavior. We can know all of the right things but not do them. Criticizing. You have nobody to blame but yourself. Bad, bad, bad. Another version of that kind of shaming. Praising. Now, this one is unique because you wouldn't expect that praise is necessarily a negative thing. And it often can be. So I think you did exactly the right thing there can actually be a roadblock because if, if you are praising someone, then in a way it puts you in a position to then not praise them if that's the right thing. Oh no. And then they start thinking, oh, if I didn't do that, then I'd be doing the wrong thing. So it's like a judgmental, uh, thing. Now there are ways that you can offer kind of validation which are not necessarily praise-oriented, and we'll talk about that, uh, going forward in some of the tools. Labeling, uh, you are an alcoholic, you need to change because you're an alcoholic. Now, if somebody uses that label for themselves, that's completely different. You know, in 12-step approaches, people often feel empowered to identify as an alcoholic. Now, if they present and they say that they identify that way, then that's different. But to give somebody that label, often again, another roadblock. Analyzing. This is what your problem is. You had this thing in childhood, and this, this is your pro— like, in a very direct kind of diagnostic, analytical way. Sometimes people can feel very judged in that sense, or just not understood if it's kind of not accurate. Reassurance. Don't worry, look on the bright side, it's all going to work out. This is a way to kind of minimize a situation, often with If people are uncomfortable talking about an area, they're going to kind of go to minimizing it through these statements. The other person, again, doesn't feel heard, feels dismissed, their problem minimized. Questioning. Well, why didn't you try? Why didn't you do that? And it's almost making them feel like, oh, maybe you think I'm too stupid to try this. And it comes off as that. Judgmental again. Avoiding: Well, you think you've got problems? Well, let me tell you, I know someone who did, or I've been through, you know. So it was a way to really take the focus off the person and put it on yourself or something else, and that person feels not heard again. So rather than these roadblocks, this is the, the, this is the motivational interviewing approach, and it can be summarized by this acronym PACE. Partnership, acceptance, compassion, evocation. And I like to use that picture of kind of the rowing. It's like keeping pace when you're rowing. Imagine like the two rowers were out of pace with each other and they're just like slamming their oars against each other and they're not getting anywhere. They're out of sync. So this is a way to be in sync with someone in a conversation, to really be with them in this particular way. And most of motivational interviewing is a way of being more than the technique. And there is technique, but if you don't have this down, then none of the technique matters. You can do technique in a way that's completely out of sync and it just doesn't click. So partnership is kind of viewing the helping relationship as you're partnering with them, almost like a travel agent. You know, you don't go to the travel agent and say, I want to go on a trip. And they're like, well, I think you should go here. You know what? Let me book it for you. Let's do it. You partner with them. It's a partnership. They ask you, where do you want to go? Well, I'm thinking over here. Okay. And then you start collaborating. So there's a collaboration that, that's there. There's not this kind of hierarchical, I'm the expert, let's, let's, let's diagnose you and figure it out. And so you're partnering with them in that process. Acceptance is kind of that Carl Rogers, uh, spirit of unconditional positive regard. It's, it's viewing— even though people can present with all kinds of things that could on the surface just seem very, you know, in everyday life be highly judged, in that relationship you're viewing the behaviors, not the person. And you're really trying to put yourself in their shoes and understand why they might be doing what they're doing, where they're coming from, and accepting them for the person they are, where they're at, with all of the potential that they do have. Compassion is doing all of this for their own benefit. Not to manipulate them for your own means. This one was thrown in there because the founders of this approach saw that motivational interviewing is highly effective in sales, and so you wanted to— they wanted to make sure that this was, was really compassionate thing rather than just trying to manipulate someone. And evocation is pulling out their own reasons for change rather than assuming their reasons or telling them their reasons. You're going to pull it out of them, and we'll see how that's done kind of throughout this process here. So here's the process of the conversation. If the oars is like you're paddling with them, where are we going? And this is kind of the journey of where we're going. First, you engage the person. Are they someone you want to talk to? Do they feel comfortable? Then you focus the conversation. OK, what do we want to focus on right now? Is the alcohol the problem or is the cannabis the problem or is it something altogether different? You want to leave that open. You don't want to say, like, oh, you know, let's get, let's really focus on that alcohol because that's bad. Cannabis, that's not that. But really the person be like, no, no, I have a couple drinks on the weekend. Actually, cannabis, I'm really addicted to it. And so you want to kind of say, is this the one you want to focus on or is this other thing what we, what we should focus on? What are your thoughts? And really focusing And then from there, you're pulling out their reasons for change. And we'll talk more about that. We'll go into each of these in depth. And then the last part is planning for that change. What does it look like after the conversation? What are the practical next steps? So these are the tools that you would use on that journey. So OARS is actually the acronym. So the picture of the oars there, and again, the rowing metaphor. These are the tools that you would use on that journey in sync with that person. So open-ended questions, questions that can't be answered with a yes or a no. So usually things that start with a what. Um, affirmations, which would be kind of pointing out their strengths, uh, values, abilities. Things like that. So it's a way to validate the person without kind of being like a praise cheerleader, like, "Good job." It's very specifically reflecting back what you're seeing in them as strengths and values in that regard. Reflections are statements summarizing or paraphrasing what you're hearing, but in your own words. And, and most of motivational interviewing is exactly this. It's mostly reflective listening. And on average, you're going to ask— maybe you do 4 reflections per open-ended question. So when we think of a conversation, we think of question, question, question. But the best way to keep the person talking in this approach is not asking questions, actually asking as few questions as possible, using as many reflections as possible. And then summaries are just longer reflective statements summarizing kind of all of the things that you've kind of heard and wrapping it all up. And so these are the— these are really the main tools that you would use with the acronym OARS along that conversational journey. So let's go to the first part of that journey here, engaging. How to engage the person again in context. We're right here in the beginning. Using ORs again, so thing we just talked about, how do you engage the person with these tools? So my go-to is, well, what led to your decision to reach out for support? What led, what led you to your call today? What, what, what would you like to, to discuss? You know, these kinds of open-ended questions. A reflective statement after that, you could say something like, so you're feeling 'Fear regarding your ability to cope with life without substances then.' And then they'll say something like, 'Yeah, and blah blah blah,' and you just keep reflecting back things you're hearing in your own words. We'll talk more about the specifics of reflection in a bit. Affirmations would be kind of pointing out, 'Oh wow, you have a lot of insight into how substances might be affecting your life.' So you're kind of affirming the insight. Or you could say, 'It took a lot of courage for you to reach out.' Or, "It sounds like you really value this." So you're really kind of pointing out those things that you're seeing. And then the summary, it would be like, "So you've tried the 12-step programs and you've also considered residential, but now you're looking to do something else." And you're like, "Okay, that's right." So these are the tools that you can use to get those "that's right" statements. You know you've engaged someone when you hear "that's right" or "right," rather than "you're right." 'Cause when you hear the words "you're right," It's almost as if like you just told them what to do. And they're like, yeah, you're right. I should. I know I should. You're right. Versus that's right, which is more of a, huh, that's right. And so the first version, you're right, the person feels disconnected, judged, kind of more like distraught. When you're hearing that's right, they feel understood, connected. Validated. And that's the therapeutic relationship. And so the more they feel that, that's when you know you've really engaged someone, when they're really saying, that's right, that's right, and they keep going and they keep going. Their kind of enthusiasm starts to build. And so once that person— so let's look at the tools to engage someone here again. So reflective statements are how you do it. This is a very simple reflection. The person says, "I feel guilty about my drinking because I often drink too much." And you say, "So the drinking is causing some guilt." Sure, you can say that. That's— it's all right. But in a way, it can, it can often come off as very obviously just kind of saying what the person just said, and it sounds like you're not even listening. And there's an old stereotype in therapy that You know, it's this one here. Did you realize your, your chair is on fire? The therapist says, I hear you saying my chair is on fire. You know, it's like that fake listening. And so what we want to do is not do this. And so complex reflections are really the bulk of it. If possible, complex reflections are like gold standard. The more you do this throughout the whole process, the better. And what it is is reflecting the implicit meaning of what is being said rather than just the words that are being said. For example, when it comes to drinking, I find it difficult to control myself. And you say, and you're looking to gain back some control. The person said, yeah, I miss the way things were before I started drinking. And you say, spending time, so spending quality time with the ones that matter. And now you're not just making this stuff up, you're pulling it from other parts of the conversation. So maybe earlier on they said something like their family is really important to them, they lost contact, and so you're kind of doing a callback to something that's important to them that they had said previously. You're really stating the implicit meaning of the things that they're saying, pointing, or you can even reflect back emotion. So they're not saying, "I'm angry," but the way they're saying it is like, "Ah, and things never change," and Or so you say something like, and you're really frustrated because it's just kind of in a rut. And so they didn't necessarily say that, but you're really kind of extending the meaning of what they're saying. It can almost sound like finishing their sentences, but without kind of making assumptions when you finish their sentence. You're really trying to put yourself in their shoes when you do it. So in short, be a person, not a parrot. And so just be Being again, when all else fails, Carl Rogers humanistic counseling style, full on. Now this is where things start to differ from Carl Rogers and the person-centered approach because it gives us some more structure here. Focusing is how do you focus that conversation rather than just letting it kind of go wherever it goes. And that's that second stage of the process. How do we do it with the tools? Well, you could focus through an open-ended question by saying something like, would it be, would it, would it be more important to focus on your alcohol use right now or your cannabis use? As I said before, so open-ended question, or is something else really the main issue? And, and letting them guide you. Again, that collaborative spirit, letting them guide the focus rather than to kind of jump to a focus. Reflection. So you want to focus on X today. Okay. Affirmations. You seem to really know your priority. And then summary would be, so you've been struggling with X and Y as well, but really want to focus on Z. And they're like, that's right. Okay. So let's focus on Z. And so that's kind of an example of how you might focus with the tools. Evoking. So I skipped through focus real fast. That's okay. Evoking is where all the magic happens in motivational interviewing. It's where the change, the change and the motivation is facilitated the most. The engaging part is, do they want to talk to you? Do they feel connected? Focusing, what are we talking about? This is really where a lot of that motivation is built in the conversation. Again, we're right here in context. So remember the ambivalence. So people present feeling like on one hand they don't want to, they want to keep doing what they're doing. On the other, they really want to change. So how do we get rid of this rather than trying to strike away the reasons not to and jumping on the reasons to? Well, let's look at what these things actually are. So we can label the reasons not to change as sustain talk. And you, you know, you're hearing sustain talk when you hear that real stuck language or a lot of discussions about the past or why I can't and how it's so hard. And to tell you the truth, most of— a lot of my conversations will consist of this, like a huge chunk. So what I'm— I'm not even here in a lot of conversations. I'm really trying to engage the person and really have them kind of work through. Like in the very beginning, while you're engaging, you can let them talk about whatever it is, but But once they are ready to really kind of start talking about more the positive reasons to change, it is keeping an ear out for the difference between the sustain talk of I am stuck and the reasons to change of like, well, you know what, I really need to do this and maybe I can do this. And you know what, I have done this before, so maybe I— and they start thinking, their wheels start spinning. And when you start to hear the change talk, how do you get more of it? Well, evoking change talk through reflective, through questions and reflective listening. And so a rule of thumb: what you reflect, you get more of. If the person says two things, they say, "I'm really stuck and I'm really frustrated and I really need to change because of my family." There's, there's a choice here. You can reflect, "So you're feeling really stuck right now?" And they'll say, "Yeah," and then they'll keep talking about the stuckness. And that's perfectly okay if you're in the engaging spot and the person doesn't feel heard yet. But if they're really showing you both and they're showing some change talk, reflecting the change talk side of it really brings more of that. So again, to that statement of, I'm really feeling stuck and frustrated and I really need to change because my family, then I would maybe reflect something like, and if you could be there for your family, you know, that would be really important to you and you would be able to kind of be the type of person you want to be like, yeah. And then, and, and so now if I reflect I reflect the change talk, I get more change talk. The more change talk, the more motivation. And that's kind of the connection between all of these things. And as they keep kind of hearing themselves talk about their reasons and what they can do, the more they want to do it. People don't believe what they hear. They believe what they say. And so if I tell them the same things that they're saying, it's not going to have an impact. But if I could pull it and evoke it out of them and they say it, they're going to believe it, and, and, and way more so than if they hear. So that's how you would kind of pull that out. And evoking with the ORs again, what is important to you? Um, so staying sober would allow you to be there for your children. Again, uh, you have really strong commitment to your values. You can even name whatever those values are. In summary, so X, Y, and Z are important reasons for you to stay sober. There's some special techniques that, that kind of fit into this. And so one of them is the decisional balance, and I really like this one kind of in a first conversation with someone. It's asking about what are the benefits of not changing first. Now, this, like that finger trap metaphor, The benefits of not changing is leaning in because you press on presents with like massive like red flag, like the, the 26er vodka they're drinking every day, that can't be good. We need to get rid of that. Let's get rid of that. That's bad. You know, it's very temp— it's kind of the obvious thing. But to lean in and say, so what are the benefits of drinking this, of not changing and continuing to drink this amount of alcohol every I mean, what is it doing for you? Um, is, is really where I would like to start. And if you don't address what it's doing for them, that just operates in the background without you knowing. Um, if you don't, if you don't know what it's actually doing for them, it gives it more power. It's like the thing you can't look at has more power. It's like Carl Jung's shadow. I can't look at the shadow. I just have to stare at the sun, but the shadow then has power over it because you're not looking at it. And so I'm going into what's actually, what's it doing? Like, what's the cannabis doing for you? What's the stimulants doing for you? And then that gives you kind of practical tools if you're using other therapeutic modalities as well after, you know, or in addition to motivational interviewing. If you're doing cognitive behavioral therapy, if the person says, yeah, I drink the alcohol because it helps my social anxiety, And so now later on in the therapeutic relationship, you can treat the social anxiety using whatever technique or modality is, is relevant, but it's giving a whole of the information right off the bat of what you need to address later. Um, what are the drawbacks of changing? So what are the benefits of staying the same and what's the drawbacks of making a change? Again, that leaning in because it's difficult to ask these types of questions because it's like, is it going to enable them to want to do it more? Because we're talking about how hard it is to change. Um, but you know, sometimes they'll say, well, because it's going to take a lot of effort or whatever it is. But when— once they've kind of gotten all the stuff on the table, this next part, they're able to see the full picture of, of what the change is going to be. And, and perhaps these these next 2 questions are actually of more benefit than how difficult these first 2 questions are. And so what are the drawbacks of not changing? So if you don't change, what's going to be a drawback here? Well, you know, I can lose everything. I can lose my house, all my money, my job. And so as they get talking about all of the drawbacks of not changing, and then to the benefits of changing— what could, what would, could your life be like actually if you did make this change? Let's take alcohol out of the equation. What's your day look like? And now they're just kind of talking about all of these, these positive elements. And this is the change talk right here. But in order to get to this, it's starting with the first stuff. And now once they've talked about all 4 of these areas, they're like, oh wow, is it even worth it now? Hmm, interesting. And their wheels are spinning again. So that's the way to kind of evoke another special technique here would be the Readiness Ruler. So very simply, it's— and I don't use this a whole lot, but every now and then it just kind of fits. It's not an assessment. The number is completely irrelevant, whatever they say, unless it's a 1. And now, if I knew the, the answer was going to be a 1, I probably wouldn't even ask this question. I'd probably go back to engaging the person, doing other things. It's asking, on a scale of 1 to 10, how ready are you to change? 1 being not ready, 10 being very ready. And so if they say something like, well, I'm kind of at a, at a 6, you would ask them, okay, so you're at a 6. What makes you a 6 rather than a 1? Now, by the way that question is framed, they have to answer with change talk. So, okay, I'm not at a 1 because, well, I've already done that, therefore I feel capable enough to do this. I do have this kind of support, so that's good. And so they're talking about all of the reasons to change, and it's just by asking it backwards that way, it evokes change talk. Now, if you wanted to move into planning, you would ask, well, how do we get from a 6 to a 7? And then they— we could start planning with them. But as a way to just evoke the change talk, whatever number they answer, why not lower? Why not a 1? Now, this is a way— there's a way to measure the strength of someone's change talk, the strength of someone's commitment or readiness to change. And you can kind of hear these little red flags in the or green flags maybe, in the language. And so, DARN CAT is the metaphor here. Desire, this is the weakest form of change talk. It's like, I kind of want to change. So I'll just skip to here. I want to change. I have a desire to change. And a lot of people have desires to do a lot of things that they don't do. Everyone says, I want to hit the gym in January. I want to stop eating sweets. I want to write my novel or memoir. I want to take that course. So people want to do a lot of things that they don't do. It's something. It's better than wanting nothing, but again, it's very weak. The next level up from that is people feeling like they have the ability. This is where a little bit of a self-efficacy comes in and people feel like they can do something. So like, well, I can do that, or I have done that, and you're starting to feel a little more confident. So when you hear those can statements. Reasons. Well, here's why. Here's why I can't change. Not just that I can do it, but why I can do it. And there's a good quote by Viktor Frankl, who's quoting Nietzsche, says, when we have a why, we can overcome any how. And so figuring out their why, evoking their why, really develops these reasons to change, and it's quite a strong level of change talk. Even stronger is need. I need to change. There's no other option. I need this, and here's why. Here's why I can. I really want this and need it. And so you're really hearing all of those things going off, and you know you've gotten some pretty strong change talk. Next is someone saying, I'm committed to taking the next step. And then, uh, really after that is just doing the change. And so just stop that, the commitment, and go to the next part. If someone's committed and you want to plan about next steps, here's the planning process again in the context of that conversational journey right at the end there. How do you use the, the tools to plan for the next step? So what are you looking to do after our conversation today? You know, in today or tomorrow timeframe, what is it that you can do? Reflecting back, so you're looking to take some time for yourself today. Yeah, so you're looking to go for a walk and do some journaling, do some mindfulness exercises. All right, okay. You're looking to join that AA meeting that we talked about? Sure, sounds good. And so you're reflecting back what you're hearing or affirmations. Oh wow, you have quite a few effective things that you could do. In summary, so you're going to do X, Y, then Z. Again, another extended version of a reflection. And so here's the overview of the whole process that we talked about. There's, you know, engage in the beginning. Are you someone they trust and can talk to? Heavily emphasizing complex reflective listening, and really not having to steer the conversation any particular way, just meeting them where they're at. You could stay there as long as necessary. I'll stay there whole sessions sometimes if someone needs to. It's holding space for that person in that engaging phase. And grief counseling is a lot of that. It's simply just holding space. You don't need to do all this other stuff. Motivational interviewing, where you see that someone's kind of on that motivational seesaw, you want to kind of add these extra components ideally. And focusing— what is it we're talking about? What's the thing right now that's most relevant? Evoking their reasons to change, hearing that change talk. You can assess the strength of it by hearing those, those darn CAT words, reflecting it back, and of complex reflection. And then those kind of techniques if necessary. So you're at a 7, why a 7, not a 1? Why a 4, not a 1? 2, why a 2, not a 1? What makes it a 2, not a 1? Whatever it is. And then if you wanted to kind of jump off of that technique into the planning stage, so you're at a 4, how can we get that to a 5? You know, what's it going to take, you know, Today or tomorrow? Well, I guess I could try this. Okay, so let's look at that. And then kind of collaboratively planning, again, like that travel agent of change rather than the diagnostic kind of expert guider person. And that's kind of the process, the tools, and the spirit, kind of the way of showing up in motivational interviewing. And that's, that's kind of the model there.