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Topic 1. MI Style and Traps ......................................... 2. MI Assessment Sandwich ............................... 3. MI Principles ................................................. 4. Using Your OARs .......................................... 5. Stages of Change ............................................ 6. Reflections ..................................................... 7. Exploring Ambivalence .................................. 8. Eliciting Change Talk ..................................... 9. Assessing Readiness to Change ....................... Page 59 61 62 64 66 68 70 72 73

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MI STYLE AND TRAPS

Teaching Tool No. 1

The interviewer does not feel obliged to answer a clients objection or resistance. In MI, the interviewer commonly turns a question or problem back to the person, and relies on the clients personal resources to find solutions to his/ her own issues. Rolling with resistance includes involving the person actively in the process of problem solving. Resistance is a signal for the interviewer to shift approach. How the interviewer responds will influence whether resistance increases or diminishes. TRAPS - MI interviewers have discovered a number of traps which prevent full use of MI style in working with substance abuse clients. Here are a few of the most common traps into which counselors can fall. 1. Question-Answer Trap. Setting the expectation that the therapist will ask questions and the client will then answer, fosters client passivity. This trap can get sprung inadvertently when you ask many specific questions related to filling out forms early in treatment. Consider having clients fill out questionnaires in advance, or wait until the end of the session to obtain the details you need. Asking open-ended questions, letting the client talk, and using reflective listening are several ways to avoid this trap. 2. Labeling Trap. Diagnostic and other labels represent a common obstacle to change. There is no persuasive reason to use labels, and positive change is not dependent upon acceptance of a diagnostic label. It is often best to avoid problem labels, or refocus attention. For example, Labels are not important. You are important, and Id like to hear more about

otivational Interviewing is not a technique but rather a style, a facilitative way of being with people. MI is a client-centered, empathetic and yet directive interaction designed to explore and reduce inherent ambivalence and resistance, and to encourage self-motivation for positive change in people presenting for substance abuse treatment. COLLABORATION - MI requires that the therapist relate to the client in a non-judgmental, collaborative manner. The clients experience and personal perspectives provide the context within which change is facilitated rather than coerced. EVOCATION - The interviewers tone is not one of imparting wisdom, insight or reality, but rather of eliciting the clients internal viewpoint. The counselor draws out ideas, feelings, and wants from the client. Drawing out motivation, finding intrinsic motivation for change and bringing it to the surface for discussion is the essence of MI. AUTONOMY - Responsibility for change is left totally with the client. Individual autonomy is respected. MI style communicates safety and support, first through an absence of confrontation or persuasion and second, by acceptance of the client. ROLL WITH RESISTANCE - Opposing resistance generally reinforces it. Resistance, however, can be turned or reframed slightly to create a new momentum toward change. The interviewer does not directly oppose resistance, but rather rolls and flows with it. Reluctance and ambivalence are not opposed but are acknowledged to be natural and understandable. The interviewer does not impose new views or goals, but invites the client to consider new information and offers new perspectives.

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3. Premature Focus Trap. When a counselor persists in talking about her own conception of the problem and the client has different concerns, the counselor gets trapped and loses touch with the client. The client becomes defensive and engages in a struggle to be understood. To avoid getting trapped start with the clients concern, rather than your own assessment of the problem. Later on, the clients concern may lead to your original judgment about the situation. 4. Taking Sides Trap. When you detect some information indicating the presence of a problem and begin to tell the client about how serious it is and what to do about it, you have taken sides. This may elicit oppositional no problem here arguments from the client. As you argue your view, the client may defend the other side. In this situation you can literally talk the client out of changing. You will want to avoid taking sides.

5. Blaming Trap. Some clients show defensiveness by blaming others for their situation. It is useful to diffuse blaming by explaining that the placing of blame is not a purpose of counseling. Using reflective listening and reframing, you might say, Who is to blame is not as important as what your concerns are about the situation. 6. Expert Trap. When you give the impression that you have all the answers, you draw the client into a passive role. In MI the client is the expert about his/her situation, values, goals, concerns, and skills. In MI style counseling you seek collaboration and give your clients the opportunity to explore and resolve ambivalence for themselves.

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MI ASSESSMENT SANDWICH
he MI Assessment protocol can be conceptualized as an MI sandwich in which a more structured standard assessment process (completion or review of completed instruments) is sandwiched in-between two client-centered MI interventions. This is designed as a single session that starts with a MI discussion using OARS (Step 1), then gently shifts to a more formalized assessment or review of already completed assessment instruments (Step 2), and then moves back to an MI discussion of change (Step 3). MI ASSESSMENT SANDWICH CONCEPT: MI strategies during opening 20 mins Agency intake assessment MI strategies during closing 20 mins

Teaching Tool No. 2

instrument or go back to specific items to elicit further discussion using an MI style before proceeding to Step 3. STEP 3: Bottom portion of sandwich focuses on strategies for eliciting change or managing resistance. The goal of Step 3 will depend very much on the readiness level of the client in terms of his or her perceived importance of the change and confidence in being able to make a change. The ultimate goal is to develop a change plan. Note to Supervisors and Mentors: You may introduce any portion of the MI sandwich in the mentoring process. The idea is that you may want to start by reviewing the initial portion (step 1) to assess and provide guidance on skill building with MI micro skills, such as OARS, before moving on to the higher skill (step 3) of bringing together information to establish a change plan. For more detailed information, see the more detailed description of the MI Assessment protocol.

STEP 1: Top of the MI sandwich involves building rapport and using the OARS microskills to elicit a discussion of the clients perception of his/her problems. During this step, the counselor is likely to get an idea of the clients initial readiness for change and the kinds of resistance may emerge. STEP 2: Middle of the MI sandwich involves either some form of psychosocial assessment (ASI or standard clinic assessment) or the review of assessments already completed which can then be used to facilitate a feedback discussion of the effects of substance use on different areas of the clients functioning. During the interview the counselor will acquire more information about the clients concerns and what he/she wants from treatment. When finished, the counselor can summarize the information obtained from the

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MI PRINCIPLES
n MI you provide low-key feedback, roll with resistance (e.g., avoiding arguments, shifting focus), and use a supportive, warm, nonjudgmental, collaborative approach. You convey empathic sensitivity through words and tone of voice, and you demonstrate genuine concern and an awareness of the clients experiences. You follow the clients lead in the discussion instead of structuring the discussion according to your agenda. Four principles paint the big picture of MI and underlie all aspects of the approach: Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy One way to remember the principles is with the alliteration: EE DD RR SS. EXPRESS E MPATHY. Empathy has been called the defining principle of MI. Empathy is a term loosely used in therapy circles, but what does it really mean? One definition (Websters) is: the capacity for participation in anothers feelings or ideas. Another way of thinking about empathy comes from Carl Rogers who popularized the term as one of the three essential pillars of client-centered therapy. Empathy means acceptance and understanding anothers perspective and feelings neutrally, without judging or evaluating in any way. Neutrality is key because acceptance does not necessarily mean approval or agreement. Typically, the word listening is associated with empathy, because one has to truly listen and hear another in order to be able to understand, accept, and empathize with him. Using reflective listening and forming reflections are ways to convey empathy using MI. For more information, see Reflections (Supervisory Tool No. 6) later in this section. DEVELOP DISCREPANCY. Developing discrepancy is where MI departs from a straight client-centered or humanistic approach because it is specifically directive. The discrepancy a MI counselor wants to
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Teaching Tool No. 3

build is that between the ways things currently are and the way a person would like things to be. One of the purposes of using an MI approach is to help a person get unstuck from their ambivalent feelings that keeps them in the same behavior patterns. By developing the discrepancy between where a person is now in their life and where s/he wants to be, the counselor is helping the client determine how important a change could be. Ideally, a client will be motivated by the perceived discrepancy between her present behavior and important goals or values that s/ he holds. Typically, it is most helpful if the client talks about the reasons for change rather than the counselor doing the talking. Part of developing discrepancy is eliciting statements from clients about the importance of attaining future goals or making changes to the status quo. When a current behavior is in conflict with overall life goals such as being healthy, living a productive existence, and providing for ones family, focusing on the discrepancy can provide motivation for change. Although the number of ways to develop discrepancy with a client is probably only limited by ones creativity, some common methods used in MI are the Decisional Balance activity (in which the Pros/Cons of current behavior and the Pros/Cons of changing are listed by the client) and values clarification exercises. See Exploring Ambivalence (Supervisory Tool No. 7) later in this section for more information. ROLL WITH RESISTANCE. Arguing for change with a client will likely trigger the client to argue against it, which the counselor may feel (or think of ) as resistance. In MI, resistance is thought of as a signal, a red light, and a time to do something else. When you feel what has traditionally been called resistance the client sounds uninterested in or unmotivated or unprepared for change in MI terms, you roll with it. Rolling means getting out of the way of resistance and not engaging it. A metaphor

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from Jay Haley and the strategic family therapists is frequently borrowed to explain rolling with resistance as psychological judo. In the martial art of judo, an attack by another is not met with direct opposition, but rather with using the attackers momentum to ones own advantage. Instead of fighting against the attacker, one rolls with the others momentum or energy and, in effect, gets out of harms way as resistance is reduced. For specific rolling strategies, see Rolling with Resistance (Supervisory Tool No. 10). SUPPORT SELF-EFFICACY. Self-efficacy is a term popularized by Albert Bandura in the 1980s as a cornerstone of his Social Learning Theory. It means a persons belief in his or her ability to carry out a specific act or behavior. It is similar to self confidence but is more specific and tied to a particular activity or behavior. Self-efficacy is critical in MI because it reflects the can do or cant do attitude that can make or break an effort for change. If one feels that making a change is very important but has no idea of how to go about making the change, ones low selfefficacy for making the change is likely to jeopardize the change attempt. One way to assess self-efficacy is by using the simple ruler described in Assessing Readiness for Change (Supervisory Tool No. 9). Instead of asking clients how ready they are to make a change, ask how confident they are on a scale of one to 10 to make the specific change under discussion.

The supporting part of this principle refers in part to the power of expectations. When a counselor believes in a client, and is able to convey this, the client is likely to have more belief in his or her ability to make the change. It works as a self-fulfilling prophecy. An MI counselor supports and enhances a clients belief in succeeding at making a change. It is not up to the counselor to make the decision for change, but rather it is the client who is responsible for making and carrying out a decision. The counselor helps provide a context conducive to change. Another strategy for enhancing self-efficacy is to explore a clients past successes (around this behavior or other behaviors). The counselor encourages the client to apply what worked to the current situation. For example, if a client has given up another substance such as nicotine, a counselor can facilitate a discussion around what steps the client took to be successful in changing that behavior. Another strategy is skill building. For example, if someone values using condoms but has low self-efficacy around negotiating their use with her partner, working with her on communication and assertiveness strategies may build her confidence in this behavior.

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USING YOUR OARS

Teaching Tool No. 3 4

Closed-ended examples not appropriate for collaboration and inconsistent with MI: Dont you think your wife and kids have been hurt enough by your using? Isnt your friends idea that you should quit using really a good one? Have you ever thought about taking the stairs instead of waiting in frustration for an elevator to take you up three floors? Closed-ended examples which are relatively neutral: Are there good things about your drug use? How long have you been concerned about your drug use? Affirm the Client: In MI, affirmations are genuine, direct statements of support during the counseling sessions that are usually directed at something specific and change oriented that the client has done. These statements demonstrate that the counselor understands and appreciates at least part of what the client is dealing with and is supportive of the client as a person. For example: I appreciate your honesty (if you know she is being honest). I can see that caring for your children is important to you. It shows commitment to come back to therapy. You have good ideas. The point of affirmations is to notice and acknowledge client effort and strength. Listen Reflectively: Listening reflectively and forming reflections is one way to be empathic. Listening reflectively is about being quiet and actively listening to the client, and then responding with a statement that reflects the essence of what the client said, or what you think the client meant. See Practicing Reflections Handout.

sing OARS helps you navigate a clients discussion through rapids of resistance and steer your counseling into calmer waters of change. Drs. William R. Miller and Stephen Rollnick, the developers of Motivational Interviewing, combined four basic MI methods to form the acronym, OARS. Using OARS can be especially helpful early in the therapy process when first building rapport, and can be useful at other times throughout the course of counseling. Using OARS also may help prevent rough waters or manage resistance. OARS stands for: Open-ended questions Affirmations Reflective listening Summaries Ask Open-Ended Questions: Asking open- versus closed-ended questions helps clients get started talking. An open question is one that does not invite one-word responses but rather encourages the client to take control of the direction of the reply, which can help the client feel more safe and able to express oneself. When a counselor starts off with several closed-ended questions, it is likely to cause the client to answer in short phrases and fall into a passive role waiting for the counselor to ask for information. Instead, with openended questions, a counselor sets an interested, open, collaborative tone. A client is then likely to provide more information, explore issues of concern, and reveal what is most important. Open-ended examples: What types of things would you like us to talk about? How did you first get started drinking? What would change in your life if you stopped using? How do you think smoking pot is related to the problems you talk about in your marriage?

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Provide Summaries: Summaries serve several purposes: 1. Communicate that you have tracked what the client said and that you have an understanding of the big picture. 2. Help structure a session so that neither client nor counselor gets too far away from important issues and can help you link what a client just said to something he offered earlier. 3. Provide an opportunity to emphasize certain elements of what the client has said. For example, providing summaries of the positive statements a client has made about change (change talk) gives the client another opportunity to hear what she or he has said in the context provided by the counselor. Summaries represent change talk statements

(statements that people make that are in the direction of change) linked together by counselor reflection. After several minutes of using OARS, a summary could serve as a check to see if the counselor is getting what the client is trying to relay. For example: So Sally, let me make sure I have got his right. You care about your children very much, and you dont want to chance having social services intervene. You believe you need to change your relationships that involve using, and arent quite sure how to do that. Is that it? Another possible ending may be saying What else would you add? The client will correct you if you are wrong and then you could reflect back to affirm you are listening and you got it.

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STAGES OF CHANGE

Teaching Tool No. 3 5

MI and stages of change are complimentary when in the context of understanding change. MI is used to help people change. Embedded in the spirit of MI is the need to meet clients/supervisees where they are. The stages of change help to identify where a person is in the change process. A counselor will use different MI strategies with clients in different stages to assist them in moving toward change.

esearchers have found that people tend to go through a similar process when they make changes and that this process can be conceptualized in a series of steps or stages. The Stages of Change model, part of the Transtheoretical Model of Change (Prochaska & DiClemente, 1984), depicts this process that people go through when they successfully make changes in their lives. Because it is a model of how people change instead of a theory of psychopathology, it allows counselors with widely differing theoretical orientations to share a common perspective.

ACTION

BRIEF DEFINITIONS OF EACH STAGE OF CHANGE

STAGE 1. PRECONTEMPLATION BASIC DEFINITION A person is not seeing a need for a lifestyle or behavior change A person is considering making a change but has not decided yet A person has decided to make changes and is considering how to make them A person is actively doing something to change A person is working to maintain the change or new lifestyle, possibly with some temptations to return to the former behavior or small lapses.

MAINTENANCE RELAPSE & RECYCLE PREPARATION

CONTEMPLATION

2. CONTEMPLATION

3. PREPARATION

PRECONTEMPLATION This graphic represents the stages as a circular wheel versus a linear stair-step model. The Stages of Change are dynamica person may move through them once or recycle through them several times before reaching success and maintaining a behavior change over time. In addition, individuals may move back and forth between stages on any single issue or may simultaneously be in different stages of change for two or more behaviors.

ACTION

5. MAINTENANCE

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KEY POINTS ABOUT THE USE OF MI WITH CLIENTS IN THE EARLY STAGES OF CHANGE: Precontemplation and Contemplation: Application of MI in precontemplation is a response to resistance. The counselor follows the clients lead. The counselor stays with the client in whatever stage of change s/he might be in. Examples work well in the early stages as concrete thinking may prevail. Estimates put 80% of people in either contemplation or precontemplation.

KEY POINTS ABOUT THE USE OF MI IN LATER STAGES OF CHANGE: Preparation, Action and Maintenance: Motivation to continue the change process fluctuates, as does ambivalence MI is used to facilitate change talk in the preparation, action and maintenance stages. MI is woven throughout the skill building process in order to maintain the clients readiness to change. MI is used as clients transition through the stages and embark on changing other addictive behaviors.

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REFLECTIONS
LISTENING is listening respectfully and actively to genuinely understand what the client is trying to say. You can demonstrate that you hear and understand another person by making REFLECTIVE STATEMENTS OR REFLECTIONS. Empathy can be felt when one is listened to reflectively and hears reflections.
EFLECTIVE

Teaching Tool No. 3 6

reflection, the counselor is trying to get at what the person means and reflect back. The client views the counselor as listening carefully and empathic. LEVEL OF REFLECTIONS 1. Repeating The first or closest to the surface level of reflection is simply repeating what someone has just said. 2. Rephrasing The next level of reflection is to rephrase what a person has just said with a few word substitutions that may slightly change the emphasis. 3. Paraphrasing Here you make a fairly major restatement of what the person has said. This typically involves the listener inferring the meaning of what was said and stating that back to the listener. It can be thought of as stating the next sentence the speaker is likely to say. This is not the same as finishing someones sentence. 4. Reflecting feeling This is a special kind of paraphrase as it achieves the deepest level of reflection because you are not necessarily reflecting content, but the feeling or emotion underneath what the person is saying. Typically, simpler reflections are used earlier in a meeting with someone, and deeper reflections are tried as the counselor gets a better understanding of the clients perspective and feelings. Increasing the depth of the reflection is a sign of increasing proficiency. TYPES OF REFLECTIVE STATEMENTS 1. Simple Reflection. This is the most basic acknowledgement of what a person has just said. It is restating what the client said without adding anything additional. Sometimes, through use of a subtle change in words, a simple reflection can accomplish a shift in emphasis. CLIENT: She is driving me crazy trying to get me to quit. COUNSELOR: Her methods are really bothering you. CLIENT: I dont have anything to say. COUNSELOR: Youre not feeling talkative today.

The first step in using reflective listening is to listen carefully and think reflectively. The key to doing this is to think in terms of hypotheses. This means that when you hear someone say something, you form a hypothesis or a best guess about what the client means. The second step is the action that results from the listening: forming reflections. You try out your guess by reflecting back what you think you heard. It is like asking, Do you mean.? without putting your words in question form. This requires differentiating a statement from a question. While asking questions has a large role in therapy, it is de-emphasized in reflective listening and forming reflections. This means your voice goes down at the end of the statement rather than up as it would in a question. Think about the phrase: Youre angry at your mother. Say it out loud both ways: Youre angry at your mother? (voice up at the end as in a question), then Youre angry at your mother. (voice down at the end as in a statement). Consider the slight difference in tone and meaning. It may feel odd to form a statement rather than a question when you are listening to someone and want to try out a hypothesis. However, reflective statements work better than questions in conveying empathy and increase how much a client talks. A question begs a response. When a client feels the need to answer a question, it has a slight distancing effect. A statement does not require a response. The speaker can go right on with his or her speech or can simply sit and think about what they have just had reflected to them. Reflections can be used strategically to emphasize aspects of the clients view, emotion, ambivalence, and change talk. When using a
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2.

Amplified Reflection. With this type of reflection, you reflect back what the person said in a slightly amplified or exaggerated form. CAUTION: make sure to do it genuinely because any hint of sarcasm may elicit an angry reaction and be perceived as unempathic. Often, the amplified reflection will cause the client to clarify or elaborate on an important aspect of what was said, especially when what was amplified revealed resistance. CLIENT: All my friends smoke weed and I dont see myself giving it up. COUNSELOR: So, youre likely to keep smoking forever. A possible reaction might be: Well, no, I do think Ill give it up when I have a family. (Starts the client thinking in the opposite direction) CLIENT: I dont know why everybody is making such a big deal over my drinking. I dont drink that much. COUNSELOR: Theres no reason for any concern. A possible reaction might be: Well, sometimes I do take it a little too far.

3.

Double-Sided Reflection. The intent of a double-sided reflection is to convey empathy. These statements are meant to capture both sides of a persons ambivalence. In using these, you can reflect back both the pros and cons of change that the client has said or at least hinted. Typically, the two sides are joined by the phrase, on the other hand. Double-sided reflections have the bonus of summarizing as well as demonstrating that you heard the client and provide the opportunity to bring together discrepant statements. CLIENT: It would stink to have to lose my job over a dumb policy because Ive been using, but no way do I want to quit partying just because thats hanging over my head. COUNSELOR: On the one hand, you value your job because it allows you to live comfortably, but on the other hand, you also enjoy using drugs with friends. CLIENT: It would be so hard to stick to a workout plan. COUNSELOR: On the one hand, trying to stick to a specific workout plan seems daunting and, on the other hand, you think your self-esteem would improve if you lost weight (second part was heard earlier in the session).

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EXPLORING AMBIVALENCE

Teaching Tool No. 3 7

change; the stronger an ambivalent client will defend the opposing point or the argument not to change. INSTEAD, in MI it is important for the counselor to come along side the part of the person that doesnt want to change and join with or help protect that side of a persons ambivalence. However, it is imperative that the client be given the freedom to talk about the side that doesnt want to change. For example: Tony said he loves smoking pot with his friends and would hate to give it up. He considers his use part of his lifestyle. On the other hand, he is worried about his job. He has a good job that he likes with a strict drug testing policy. If you encourage Tony to quit because he needs to keep this job and it could be in jeopardy if he continues to use, he is likely to tell you all the reasons why he should continue to smoke pot. In contrast, if you explore the status quo and acknowledge how much he enjoys smoking pot, he receives the message that you are listening and are not rushing to change him. You learn more about the thoughts and feelings that underlie his marijuana use, which are strong forces in maintaining the behavior. You have signaled that you are concerned with exploring his whole person. After talking about staying the same, he will feel the itch to talking about the other half of the story, the reasons he wants to quit. Ambivalence is not always a circle cut exactly in half. For someone in precontemplation (who is not considering change), the part that doesnt want to change might be much larger than the part that does want to change. However, both parts are still represented. At times, such as when a person is moving through the stages of change, the side that wants to change may get bigger and bigger. It may also shrink down again. This can happen from session to session or even minute to minute. The most important point about ambivalence is that having it is normal and fluctuation is normal. DECISIONAL BALANCE In MI, success in treatment is largely determined by the ability of the counselor to help the client explore and resolve his or her ambivalence in favor of change.

key assumption in MI is that people do not usually come to therapy ready for change. This does not mean they do not want to change but rather that they feel two ways about it: they want to change and they want things to stay the same. Staying the same often represents comfort, familiarity, and certain pleasures. The reasons for change need to be stronger than the reasons for staying the same in order to tip the balance for change. Pretend that the circle below represents ambivalence. One way of viewing it is that each side represents one way of thinking about change. The left side represents the part of a person that doesnt want to change. The right side represents the part of a person that does want to change.

PROS +S
GOOD
THINGS

CONS S
NOT SO
GOOD THINGS

What is likely to happen when you push or argue with the part of a client that wants to change, encouraging him to change the behavior and pointing out all the reasons for change? Typically, the client will feel compelled to talk about the other sidethe side that does not want to change. WHY IS AMBIVALENCE COMMON? This phenomenon happens because the client feels two ways about change. When trying to be convinced of all the reasons to make a change, a client feels the need to present the other side of the story because it is as important as the side being reflected by the counselor. The stronger the counselor argues his or her point for
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A tool that can help a client explore and resolve ambivalence is the Decisional Balance or Pros and Cons worksheet. It is used as a means of exploring the good and not-so-good things about the behavior in question. If used during a session, the counselor can facilitate the process by eliciting client responses. The responses would correspond with each of the four quadrants representing differing aspects of changing the behavior or making a change. The counselor may use the decisional balance a number of ways: as a homework assignment, as an activity during the session, or as a virtual worksheet where the quadrants are filled in verbally. The counselor can ask the client to:

List all the good things about the current behavior. List all the not-so-good things about the behavior. List what would be good about changing. List what would not be so good about changing. If the client fills out the worksheet as homework, it can be reviewed at the next session. It is important to review each quadrant and explore the reasons behind each listing, eliciting the clients thoughts and feelings about each item. Often the counselor needs to prompt client for the good things about the behavior. After discussing each quadrant, a counselor summarizes responses to the activity as a whole and asks the client for any changes or additions. A wealth of information about the motivators of the behavior, the reasons for wanting to change the behavior and the barriers to quitting are often revealed with this exercise.

DECISIONAL BALANCE WORKSHEET

(Fill in what you are considering changing)

Good things about behavior:

Good things about changing behavior:

Not so good things about behavior:

Not so good things about changing behavior:

Important to remember: The counselor does not suggest items that the client should put in quadrants, but instead lets the client determine from his or her perspective the pertinent issues.

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ELICITING CHANGE TALK

Teaching Tool No. 3 8

To keep my truck driving license, I should probably cut down on my drinking. My husband may leave me if I keep using. I dont like my kids to see me like this. N = Need statements. Statements that indicate a need for change. These can be similar to R statements, but the emphasis is more affective or emotional than a more cognitive R statement. Its really important to my health to change my diet. Something has to change or my marriage will break. Ill die if I keep using like this. These DARN statements are important to recognize and then emphasize through reflecting or directing the client to further elaboration. These statements are avenues to the most important part of change talk, the C in the DARN C, Commitment language. Commitment language is the strength of change talk. For example, a person could say, I might change, or I could consider changing, or Im planning to change or I will change. The last two examples represent authentic commitment. The strength of the verb in the sentence corresponds with the strength of the commitment language. An important counselor skill is addressing client commitment to change over the course of the interview by recognizing and responding to change talk. The goal is a strengthening of the commitment level. Amrhein and Miller (2003), a linguist and a psychologist respectively, have shown that while all elements of change talk can be important in building commitment language, it is the stronger commitment statements that predict positive behavior outcomes. In other words, the more a client is making strong commitment statements like I will do this and I am going to do that, the more likely the clients behavior is going to change. For more information about change talk and how to recognize it, see Enhancing Motivation for Change In Substance Abuse Treatment (CSAT TIP 35, 1998)

liciting change talk, or self motivational statements, is a crucial component and primary goal when using a MI approach. It differs from OARS in that it is more directive. Using OARS will help keep you afloat and may help steer you in directions you and the client want to go, but it may not get you to the final destination. Eliciting change talk is a strategy to help establish and resolve ambivalence and move forward. Change talk is the client making statements that are in favor of change, which suggests that the client is becoming more ready, willing, and able to make a change. However, although a counselor may want to hear change talk, an MI counselor avoids imposing it. The goal is to elicit it from the client in a collaborative fashion. Eliciting change talk has to come about through a consensual, negotiated process between the counselor and client. Change talk can occur in several forms that make up the acronym DARN C. D = Desire statements. Statements indicating a desire to make a change. Id like to quit drinking if I could. I wish I could make my life better. I want to take better care of my kids. Getting in shape would make me feel so much better about myself. A = Ability statements. Statements that speak to the clients self-efficacy or belief in the ability to make changes. I think I could do that. That might be possible. Im thinking I might be able to cut back on cigarettes. If I just had someone to help me, I could probably quit using. R = Reasons statements. Statements that reflect the reasons the client gives for considering a change. I have to quit smoking because of my asthma.
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MIA:STEP

ASSESSING READINESS TO CHANGE

eadiness, or being ready to make a change, can be thought of as a function of the relationship between how important it is for a person to make a change (how much the client values the change) and how confident the person is in their ability to make the change. Readiness is critical in the Stages of Change (Prochaska & DiClemente, 1992). Each stage in the model represents a different level of readiness to make a change. A fourth way to assess readiness is to determine which stage a client is in regarding a specific behavior. Even within a stage, there can be variation in readiness over time. Readiness is voiced through self-motivating statements or expressed reasons for change are forms of Change Talk and convey the strength of a commitment a client has to changing behaviors. A counselor using MI wants to draw change talk from the client. Some statements will convey a high degree of readiness: Ive decided that Im going to stop smoking today. Others convey only a thread of readiness: Someday I might want to cut back on my drinking. Many statements are more in the middle: I might be interested in quitting if I thought I could do it. Importance, confidence and readiness can be assessed a number of ways: Through a basic scaling rulereither on paper or verbally Through the clinical interviewlistening for clues about readiness

Teaching Tool No. 9

Through specific inventories designed to measure readiness 1. READINESS RULERS- IMPORTANCE AND CONFIDENCE. One simple assessment tool for assessing where the client is on different dimensions of readiness is a two-part scaling ruler. You can ask a client: On the following line, make a mark at the point that best reflects how important it is to you to change behavior:

... 1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10 Not at all important Very important

Next, you can ask: On the following line, make a mark at the point that best reflects how confident you are that you can change behavior:

... 1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10 Not at all confident Very confident

Another option: You can use the readiness ruler exercise by verbally asking for a number between 0 and 10 without using the printed ruler. Follow-up questions: Once the client gives you a number, you can followup my asking: You picked a 7, why not a 3? Why wasnt it a lower score?

Section E: Supervisory Teaching Tools

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Motivational Interviewing Assessment:

Supervisory Tools for Enhancing Proficiency

While this allows for the counselor to elicit change talk, the client will impart his or her DARN (Desire, Ability, Reasons, Need) for change. 2. KEY QUESTIONS ON READINESS for use during a clinical interview session. The clients response will help you gauge readiness. Responses may involve change talk. Simply hearing oneself make such statements may help move the client further along in the direction of change. What do you think you will do? What does this mean about your (habit)? What do you think has to change? What are your options? Whats the next step for you? What would be some of the good things about making a change? Where does this leave you? If the client shows readiness to develop a plan for action, you can brainstorm with (not for) him or her. Many possible courses of action exist: Lets look at some of the options together. Patients ideas supplemented by things that you know have worked for others You will be best judge of what works for you. Which one suits you the best? Convey optimism and willingness to reexamine the clients overall readiness through importance and confidence. 3.

Remember successes (support self-efficacy), especially if confidence is low. What made your most recent successful attempt different from previous efforts? What previous skills can be built into a new plan? Break the plan into components and ask which one patient feels most confident about. INVENTORIES TO ASSESS READINESS. The URICA and SOCRATES are two instruments used to more formally assess readiness. There are others. For more information on these, see Enhancing Motivation for Change in Substance Abuse Treatment (CSAT TIP 35, 1998). The URICA is the University of Rhode Island Change Assessment Scale (McConnaughy, et al., 1989), which is also referred to as the Stages of Change (SOC) scale. The original version contains 32 5-point Likert questions that measure 4 stages: precontemplation, contemplation, action and maintenance. The SOCRATES is the Stage of Change Readiness and Treatment Eagerness Scale (Miller & Tonigan, 1996). Readiness is factored into three dimensions: Recognition, Ambivalence, and Taking Steps. Two separate scales use items targeted toward problematic alcohol or drug use. Both long (39 items) and short (19 items) scales are available.

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