1. MOTIVATIONAL
INTERVIEWING:
HELPING OTHERS
CHANGE
Cari Guthrie Cho, LCSW-C
VP of Programs
St. Luke’s House & Threshold Services
United

2. READY TO CHANGE?
Willing= In order to be ready to change Able=
Importance Confidence
The patient must be both willing and able

3. STAGES OF CHANGE
 Pre-contemplation. Client is unconvinced that
s/he may have a mental health and/or substance
use problem and does not believe s/he needs to
change. S/he may have given up or have not
been committed to consistent treatment. Clients
often feel pressured by others to seek treatment.
 Contemplation. Client is actively considering
the possibility of change in regards to mental
health and or substance use. S/he is evaluating
his/her behavior and options, but is not ready to
take action yet. S/he may have made attempts to
change in the past.

4. STAGES OF CHANGE
(CONT)
 Preparation. Client makes a commitment to
change and starts making initial plans to
actually change his/her behaviors.
 Action. Client begins to make actual behavior
change, and to use new ways of dealing with
situations.
 Maintenance. Client begins to consolidate new
behaviors and new ways of thinking into his/her
regular daily life.

5. COMMUNICATION
STYLES
Direct - lead, tell, show the way, take charge of,
preside, govern, rule, have authority, exert
authority, take the reins, take command,
control,
Follow - go along with, allow, permit, be
responsive to, have faith in, shadow, understand,
observe
Guide - enlighten, shepherd, encourage, motivate,
Support, accompany, collaborate, promote,
elicit solutions, evoke insight

6. MI: A WORKING
DEFINITION
“Motivational interviewing is a person-
centered, goal-oriented method of
communication for eliciting and
strengthening intrinsic motivation for
positive change.”
(Miller, 2009)

7. 10 THINGS MI IS NOT:
 A way of tricking people into doing what you want
them to do
 A specific technique (MI is a counseling method; no
specific technique is essential)
 A decisional balance, equally exploring pros and
cons of change
 A form of cognitive-behavior therapy
 Easy to learn
 What you were already doing
 A panacea for every clinical challenge
(Miller, 2009)

8. EXERCISE – HAVE A LOOK
Client: I just feel so full of shakes that I take a drink before I leave the house.
Counselor: Yes it will be good to drink less. How much do you drink these
days?
Client: Well, I’m not an alcoholic its just that I need it before I leave the house.
Counselor: How much would you say you drink each week, even just a guess?
Client: Well you know, I don’t know. I only drink wine so maybe just a few
glasses a day, sometimes more, I need it to calm down really.
Counselor: Yes, I see that’s probably at least around 20 – 30 glasses a week.
Do you drink even when you go to pick up the kids?
Client: I don’t like to drink as much as I do, but when I am nervous, then I
take a drink but its really not very much.
Counselor: Yes and how often does this happen when you are with the
children?
Client: Well, I don’t always drink wine before I go get the kids, but you have no
idea how terrified I get, its like walking through a mist out there. Today I
had to hang on to a lamp post to keep steady and not faint. Its just horrible.
Counselor: And did you have a drink before you came out?
Client: Just a little one to be honest but I’m not an alcoholic you know.

9. HAVE A LOOK AGAIN!
Client: I feel so full of shakes that I take a drink before I leave the house.
Counselor: It helps to settle your nerves.
Client: And I can go get the kids from school, shop and then feed them.
Counselor: and you get quite a lot done.
Client: yes, those kids keep me going for hours after that, you know the food,
playing, going to bed and they are not easy, shouting all the time.
Counselor: you’ve told me about those panic attacks, how you work so hard to
look after the kids and how you sometimes need a drink before you leave the
house.
Client: yes, that’s exactly right.
Counselor: May I ask you, could we spend a few minutes talking about alcohol,
how it helps and what else you’ve noticed about it?
Client: well as I said, it calms my nerves, but it can’t go on like this forever.
Counselor: although it helps, you’re concerned about it.
Client: well, I’m not an alcoholic you know but I can’t be drinking while I am
with the kids.
Counselor: you don’t want your life to revolve about drinking.
Client: exactly you know I must watch it.

10. REASONS FOR
PRACTICING MI
 It works!
 It’s all in the welcoming, and welcoming is
easy
 It doesn’t cost much
 Small intervention, big effect!
 The opposite approach, confrontational
counseling, has poor results
 It fits well with other treatment interventions
 It makes our jobs easier and more enjoyable
 Robust and enduring effects when MI is added
at the beginning of treatment
 MI increases treatment retention, adherence
and staff-perceived motivation

13. MI SPIRIT
MI Spirit - a style, attitude or approach. A way of
being when talking about change. A powerful
ingredient in the fuel that drives good practice.
Collaborative – working with the client –
respect the client’s expertise; understand their
goals.
Evocative – drawing out ideas and solutions
from the client as the experts about
themselves.
Honor autonomy – decision making is left to
the client. They are ultimately responsible.

14. WHAT ARE THE BENEFITS OF
EXPRESSING EMPATHY – (REFLECTIVE
LISTENING)?
 Establishes rapport
 Shows it’s safe to talk
 Builds trust
 Promotes understanding
 Helps us both feel better
 Helps client to be more open to self-
exploration
 Opens doors to finding a solution that
meets client motivations
 Etc?
Guy Azoulai, MINT, Aunay Sous Bois, France, 2006

15. HOW CAN WE EXPRESS EMPATHY ?
having clients explore solutions for
their own dilemmas
keeping our agendas under wraps
allowing us to avoid road blocks to
listening
reflecting what the client says
using YOU and WE vs I
asking permission before
informing
Guy Azoulai, MINT, Aunay Sous Bois, France, 2006

16. PERSON-CENTERED
COUNSELING SKILLS: OARS
 Open Questions
 Open the door, encourage the client to talk
 Do not invite a short answer
 Leave broad latitude for how to respond
 Closed Questions
 Have a short answer (like yes/no)
 Did you drink this week?
 Ask for specific information
 What is your address?
 What medications do you take?
 Might be multiple choice
 What do you plan to do: quit, cut down, or keep on smoking?
 They limit the client’s answer options

17. ARE THESE QUESTIONS OPEN OR
CLOSED?
 What would you like from treatment?
 Was your family religious?
 Tell me about your drinking; what are the good
things and the not so good things about it?
 If you were to quit, how would you do it?
 When is your court date?
 Don’t you think it is time for a change?
 What do you think would be better for you – AA
or Women for Sobriety?
 What do you like about cocaine?
 What do you already know about buprenorphine?
 Is this an open question?

18. AFFIRMATIONS
 Emphasize a strength
 You’re a strong person, a real survivor
 Notice and appreciate a positive action
 I appreciate your openness and honesty today
 Thanks for coming in today.
 I like the way you said that
 Express positive regard and caring
 I hope this weekend goes well for you!
 Should be genuine
 Differs from praise – not an opinion or judgment
 Strengthen therapeutic relationship

19. REFLECTIVE LISTENING
 Convey understanding of the clients’ point of view
and underlying wants without asking a question.
 Demonstrates to the client that you care and are
interested in them. It is an essential tool to build
rapport.
 Does not mean that you will agree with everything
the client is saying – it is your attempt to understand
the “Gist”, the real meaning of what they are
communicating.
 It asks, in a way, “Is this what you mean?” without
asking a question.
 Reflective statements often start with “So you feel…”
“It sounds like you…” or “You’re wondering if…”

20. SIMPLE REFLECTIONS
 Repetition – simply repeating a word or part of what
was said. Do not add anything new.
 Rephrase – Stay close to what the person is saying by
taking some part o what they said and substituting this
with a slight rephrase. Here you are adding to and
building on what was said. For example:
 Client: “I really hate my job. Everyone is always on my case
to do this and get that done….”
 Staff: “You feel like everyone is demanding a lot from you…”
If you are correct, they will continue to talk and
explore; if you are incorrect, they will say “no” and then
it is up to you to start to clarify.

21. AMPLIFIED/COMPLEX
REFLECTIONS
 Paraphrase – This is a major statement in which you are
inferring or drawing together the meaning in what they are
saying and reflecting it back to the client in different words.
You are adding something to it. The goal of paraphrasing is
to get the client to explore and clarify issues.
 Client: “I really hate my job. Everyone is always on my case to
do this and get that done….”
 Staff: “Sounds like the pressure is too much for you right now”
 Reflection of feeling – This is the deepest form of reflection.
It is a paraphrase that emphasizes the emotional dimension
of the message.
 Client: “I really hate my job. Everyone is always on my case to
do this and get that done….”
 Staff: “Sounds like you are really frustrated right now.”

22. DOUBLE-SIDED
REFLECTIONS
 With a double-sided reflection, the counselor
reflects both the current, resistant statement, and a
previous, contradictory statement that the client
has made.
 Client: "But I can't quit drinking. I mean, all of
my friends drink!“
 Counselor: "You can't imagine how you could not
drink with your friends, and at the same time
you're worried about how it's affecting you.“
 Client: "Yes. I guess I have mixed feelings.”

23. PICK OUT THE REFLECTIVE
STATEMENTS
Client: I feel so full of shakes that I take a drink before I leave the house.
Counselor: It helps to settle your nerves.
Client: And I can go get the kids from school, shop and then feed them.
Counselor: and you get quite a lot done.
Client: yes, those kids keep me going for hours after that, you know the food,
playing, going to bed and they are not easy, shouting all the time.
Counselor: you’ve told me about those panic attacks, how you work so hard to
look after the kids and how you sometimes need a drink before you leave the
house.
Client: yes, that’s exactly right.
Counselor: May I ask you, could we spend a few minutes talking about alcohol,
how it helps and what else you’ve noticed about it?
Client: well as I said, it calms my nerves, but it can’t go on like this forever.
Counselor: although it helps, you’re concerned about it.
Client: well, I’m not an alcoholic you know but I can’t be drinking while I am
with the kids.
Counselor: you don’t want your life to revolve about drinking.
Client: exactly you know I must watch it.

24. SUMMARIZING
Summarizing – summarizing is a special application of reflective
listening that links together discussed material, demonstrates
careful listening and prepares the client to move on.
 It may begin with a statement indicating that the staff is
attempting to summarize. For example:
 “Let me see if I understand what you’ve told me so far…”
 “Okay, here’s what I’ve heard so far. Listen and tell me if
I’ve missed anything….”
 Make your summary concise.
 End with an invitation for the client to respond such as:
 “How did I do?
 “What have I missed?”
 “So if that is a fair summary, what other points are there to
consider?”
 “Is there anything there you want to correct or add to?”
 Summaries are good to use when you feel lost or if you want to
change direction in the conversation.

25. Thomas Gordon’s
12 Roadblocks to Listening
1) Ordering, directing
2) Warning, threatening
3) Giving advice, making suggestions, providing solutions
4) Persuading with logic, arguing, lecturing
5) Moralizing, preaching
6) Judging, criticizing, blaming
7) Agreeing, approving, praising
8) Shaming, ridiculing, name-calling
9) Interpreting, analyzing
10) Reasoning, sympathizing
11) Questioning, probing
12) Withdrawing, distracting, humoring, changing the subject

26. OARS Exercise:
 Work in groups of 3
 One speaker and two counselors
 Counselors take turns speaking
Speakers:
 Describe something about yourself that you
 Want to change
 Need to change
 Should change
 Have been thinking about changing
 But you haven’t changed yet – i.e. something you are ambivalent about
Listeners:
 Respond to the speaker using OARS
 Don’t try to fix it or make change happen!
General Guidelines with OARS
 Ask fewer questions – 50% of what you say should be reflections
 Ask more open than closed questions – 20% open questions
 Don’t ask 3 questions in a row – throw in some reflections and affirmations
 Offer two reflections for each question asked
 Summarize when you have gathered a lot of info that you want to organize or to
move to another topic or to end the session.

27. Raymond: Active Listening

28. RESISTANCE IS…
 A defense mechanism that signals to you that the
client views the situation differently. This is
seen throughout all stages, but is often addressed
in the contemplation stage as ambivalence.
 An important signal of dissonance within the
counseling process
 Often associated with drop-out rates and other
poor outcomes
 It is a signal to staff that they need to change
direction or listen more carefully.*
 It offers an opportunity to respond in a new,
perhaps surprising way with out being
confrontational.*
Normal

29. OK, IT’S NORMAL…NOW
WHAT?
 How we respond to client resistance or sustain talk
makes a difference and distinguishes MI from other
counseling approaches
 MI assumes that if resistance or sustain talk is
increasing during counseling, it is very likely in
response to something the counselor is doing
 Sometimes the most (and best) we can do with a
particular client is to reduce resistance
 Implicit in the MI approach is an assumption that
persistent resistance is not a client problem, but a
counselor-approach or -skill issue
 SO: We can change our style in ways that will
decrease client resistance…and decreased client
resistance is associated with long-term change!

30. FOUR CATEGORIES OF
CLIENT RESISTANCE
 Arguing – the client contests the accuracy, expertise, or integrity
of the clinician or what they are saying by challenging,
discounting or being hostile towards the staff person.
 Interrupting – breaks in and interrupts in a defensive manner by
talking over or cutting off the staff.
 Denying – client is unwilling to recognize problems, accept
responsibility, or take advice
 Minimizing
 Blaming
 Rationalizing
 Intellectualizing
 Diversion
 Hostility
 Ignoring – the client shows evidence of ignoring or not following
the clinician by inattention, no response, or sidetracking the
conversation.

31. SIX (WELL, SEVEN) TRAPS TO AVOID…AND
THEY USUALLY ARISE EARLY IN THE
INTERVIEW PROCESS AND RE-APPEAR WHEN
WE ENCOUNTER RESISTANCE
 The Question-Answer Trap
 The Expert Trap
 The Trap of Taking Sides
 The Labeling Trap
 The Premature Focus Trap
 The Blaming Trap
 And…the Righting Reflex…watch for it
throughout…

32. IDENTIFY THE CHANGE TALK
Client: I feel so full of shakes that I take a drink before I leave the house.
Counselor: It helps to settle your nerves.
Client: And I can go get the kids from school, shop and then feed them.
Counselor: and you get quite a lot done.
Client: yes, those kids keep me going for hours after that, you know the food,
playing, going to bed and they are not easy, shouting all the time.
Counselor: you’ve told me about those panic attacks, how you work so hard to
look after the kids and how you sometimes need a drink before you leave the
house.
Client: yes, that’s exactly right.
Counselor: May I ask you, could we spend a few minutes talking about alcohol,
how it helps and what else you’ve noticed about it?
Client: well as I said, it calms my nerves, but it can’t go on like this forever.
Counselor: although it helps, you’re concerned about it.
Client: well, I’m not an alcoholic you know but I can’t be drinking while I am
with the kids.
Counselor: you don’t want your life to revolve about drinking.
Client: exactly you know I must watch it.

33. EVOCATIVE QUESTIONS –
MAGIC!
 For what are you motivated?
 What change do you want most?
 On a scale of 1 – 10, how important is it to you to
change?
 What are your most important reasons for
changing?
 What are the benefits of changing?
 What steps are you willing to take?
 How will you do it?
 In what ways are you already able to make the
changes you want to make?
The answers to all of these are CHANGE TALK!

34. DECISIONAL BALANCE
Status-quo
Benefits of Changing Benefits of Not Changing
Change
Consequences of Changing Consequences of Not Changing
34

35. SIGNS OF READINESS FOR
CHANGE
 Decreased resistance
 Decreased discussion about the problem
 Resolve
 Change talk/self-motivational statements
 Questions about change
 Envisioning
 Experimenting

36. FINAL THOUGHTS…
 MIreleases us from the draining
psychological burden of having to “make”
people do the right thing, which is
actually an impossible task.
 Peoplemake choices and we cannot take
that away from them…what we CAN do is
help them make the choices that are right
for them.

37. FOR YOUR INTEREST
 Miller and Rollnick (2002). Motivational Interviewing:
Preparing People for Change, 2nd Edition, New York, Guilford
Press.
 Rollnick, et. al. (1999). Health Behavior Change: A Guide
For Practitioners. London and New South Wales, Churchill
Livingstone.
 Miller and White. Confrontation in Addiction Treatment,
Counselor, August 2007.
 Miller, W. R. (2000). Rediscovering Fire: Small
interventions, large effects. Psychology of Addictive
Behaviors, 14:6-18.
 www.motivationalinterview.org
 Enhancing Motivation to Change in Substance Abuse
Treatment, CSAT, TIP 35.
 Hettema, J., Steele, J., & Miller, W. R.. (2005). Motivational
interviewing. Annual Review of Clinical Psychology, 1, 91-
111.
 Amrhein, et. al. (2003) Client Commitment Language During
MI Predicts Drug Use Outcomes. Journal of Consulting and
Clinical Psychology, 71, 862-878.