Psychology
MI Brief Notes Dr Scott Hall
The nature and dynamics of conversations about change
Communication styles DIRECTING / GUIDING / FOLLOWING
Fundamentals • Motivational interviewing is a collaborative conversation style for strengthening a person’s own
motivation and commitment to change. • The overall style of MI is one of guiding, which lies between and incorporates elements of
directing and following styles. • Ambivalence is a normal part of preparing for change and a place where a person can remain
stuck for some time. • When a helper uses a directing style and argues for change with a person who is ambivalent, it
naturally brings out the person’s opposite arguments. • People are more likely to be persuaded by what they hear themselves say
Core features • MI is a person-centred counselling style for addressing the common problem of ambivalence
about change. • MI is done for or with someone, not on someone • Four key aspects of the underlying spirit of MI are partnership, acceptance, compassion and
evocation • Acceptance includes four aspects of absolute worth, accurate empathy, autonomy support and
affirmation
Four key processes in MI are engaging, focusing, evoking, and planning. • Engaging is the process of establishing a helpful connection and working relationship. • Focusing is the process by which you develop and maintain a specific direction in the
conversation about change. • The process of evoking involves eliciting the client’s own motivations for change and lies at the
heart of MI. • The planning process encompasses both developing commitment to change and formulating a
concrete plan of action. • Five key communication skills used throughout MI are asking open questions, affirming,
reflecting, summarising, and providing information and advice with permission.
ENGAGING
• Engaging is the process of establishing a mutually trusting and respectful helping relationship. • Beginning consultation with assessment can place the client in a passive role and compromise
engagement. • Expert-driven directing does not work well when what is needed is personal change. • The premature focus trap involves trying to focus too early “on a goal without sufficient
engagement. • Arguments about the appropriateness of a diagnostic label can be counterproductive. • Informal chat is not likely to be very helpful beyond modest doses.”
Listening • The learnable skill of reflective listening (“accurate empathy”) is fundamental in all four
processes of MI. • The essence of a reflective listening response is a statement that makes a guess as to what the
person means.
• Reflections vary in depth from simple repetition to complex reflections and “continuing the paragraph.”
• If it feels like you’re going around in circles or getting nowhere, the reflections are probably too simple.
Road blocks to true listening
1. Ordering, directing, or commanding
2. Warning, cautioning, or threatening
3. Giving advice, making suggestions, or providing solutions
4. Persuading with logic, arguing, or lecturing
5. Telling people what they should do; moralising
6. Disagreeing, judging, criticising, or blaming
7. Agreeing, approving, or praising
8. Shaming, ridiculing, or labeling
9. Interpreting or analysing
10. Reassuring, sympathising, or consoling
11. Questioning or probing
12. Withdrawing, distracting, humouring, or changing the subject
Core interviewing skills • OARS is an acronym for four of the core counselling skills in MI: asking Open questions,
Affirming, Reflecting, and Summarising. An open question invites a person to reflect before responding and provides plenty of latitude for how to answer, whereas a closed question constrains the range of possible replies and usually yields a short answer.
• To affirm is to recognise, support, and encourage the client’s strengths and efforts. • A summary pulls together information that the client has offered and can be collecting, linking,
or transitional.
Exploring values and goals • A key in appreciating another’s internal frame of reference is to understand his or her core goals
and values. • Self-actualisation involves moving toward one’s natural, ideal, mature state, or telos. • A values interview explores the person’s core goals: why they are important and how they are
expressed. • To live with integrity is to behave in a manner that is consistent with and fulfils one’s core
values. • Discrepancy between current behavior and a core value can be a powerful motivator for change
when explored in a safe and supportive atmosphere. • Self-regulation is the capacity to formulate a plan of one’s own and implement behaviour to
carry it out.” • To “confront” means to come face to face, and self-confrontation is usually more powerful than
being confronted by someone else.
FOCUSSING
• The process of focusing involves finding one or more specific goals or intended outcomes that provide direction for consultation.
• Focus can arise from the client, the context, or the clinician.
• The general counselling styles of directing, guiding, and following also describe three approaches to focusing.
• Sometimes there is a clear single focus, sometimes there are several possible topics, and sometimes the focus is quite unclear and exploration is needed.
• In MI, focusing is a collaborative process of finding mutually agreeable direction. • When there is a reasonably clear set of possible topics for conversation and consultation, the
task is agenda mapping to choose and prioritize. • Agenda mapping is a meta-conversation by which you step back for a short time to consider with
the client the way ahead.” • Agenda mapping can also be useful when changing direction, getting unstuck, raising a difficult
topic, or clarifying roles. • When the goals of consultation seem more diffuse, a process of orienting is needed that can
include formulation—putting puzzle pieces together in a way that generates a provisional hypothesis about where to start.
When goals differ • An ethical issue within helping relationships is whether the clinician should encourage resolution
of ambivalence in a particular direction. • Ethical concerns arise particularly in situations where the clinician or institution has an aspiration
for change that the client does not (yet) share. • Four key ethical considerations in such situations include non-maleficence, beneficence,
autonomy, and justice.” • It is inappropriate to use MI to influence choice when the practitioner has a personal or
institutional investment in a certain outcome, especially when this is combined with coercive power. This pertains in particular to the MI process of evoking.
• The use of particular processes in MI should be adapted to the client’s needs; for example, evoking may be unnecessary or even detrimental with clients who have already decided to make a change.
Elicit provide Elicit - Exchanging information • Within MI, information and advice are offered with client permission. • Elicit–provide–elicit is a sequence for information exchange that honours the client’s expertise
and autonomy. • Regarding advice: engage first, use sparingly, emphasise personal choice, and offer a menu of
options. • Self-disclosure involves a willingness to share something of yourself that is true when there is
good reason to expect that it will help and not harm the client. • Any necessary assessment should be done in a context that promotes engagement and makes
the process useful to the client as well as to the clinician and system.
EVOKING
Ambivalence and change talk • Ambivalence, the simultaneous presence of conflicting motivations, is a normal human process
on the path to change. • In natural language, ambivalence is reflected in a mixture of change talk and sustain talk. • Preparatory change talk (e.g., desire, ability, reasons, and need) tends to precede mobilising
change talk (e.g., commitment, activation, and taking steps). • The evoking process is intended to help resolve ambivalence in the direction of change.”
Evoking the persons own motivation • A client’s balance of change talk and sustain talk predicts change, and is substantially influenced
by the interviewer. • Perhaps the simplest method for evoking is to ask open questions that elicit change talk. • A variety of other strategies can be used to evoke the client’s own motivations for change.
• In MI one would not routinely elicit and explore sustain talk, although there can be strategic reasons for doing so.
Responding to change talk • When a client offers change talk, the interviewers next response should be one which
recognises and then strengthens it, such as asking for elaboration, affirming, reflecting or summarising
• A summary tends to reinforce what it contains, whether that be demoralisation, ambivalence, defensiveness or motivation for change
• The normal structure of an MI consistent summary is a bouquet of the clients own change talk
Responding to sustain talk and discord • Sustain talk is a normal part of ambivalence and should not be interpreted as “resistance” • The phenomenon of “discord” suggests dissonance in your working alliance • Both sustain talk and discord can be significantly increased or decreased depending upon how
the interviewer responds • Discord can arise for different reasons across the four key processes (E, F, E, P)
Evoking hope and confidence • People are reluctant to commit to change unless they have some kind of confidence that it is
possible • Clients with high importance and low confidence need a different kind of approach that those
with low importance and high confidence • The clinical style of hope and confidence can be used to strengthen hope and confidence
Neutrality • Neutrality of “eqiupoise” is not a counsellor quality but a conscious decision to avoid the
temptation to influence the direction in which ambivalence is resolved • Understanding the linguistic dynamics of change is helpful in knowing how to counsel with
neutrality • Decisional balance is an appropriate strategy to use when one chooses to counsel with
neutrality rather than encouraging change in a particular direction
Developing discrepancy • Change tends to occur when a person perceives a significant discrepancy between important
goals or values and the status quo. • In order to be motivating, a discrepancy needs to be large enough to encourage change but not
so large as to be demoralising. • A variety of MI strategies can be used to instill discrepancy within the bounds of the person’s
own values.
PLANNING
From evoking to planning “a bridge to change” • The time to move from evoking to planning is a clinical judgment call guided by signals of
readiness from the client. • Recapitulation and a key question is one procedure for discerning whether planning is timely. • It is unwise to proceed with change planning before clients are ready.
Developing a change plan • Developing a change plan usually involves moving from general intention to a specific
implementation plan. • Three planning scenarios are (1) the change plan is already clear; (2) there are options among
which to choose in path mapping; (3) the way forward is unclear and a change plan needs to be developed from scratch.
• The planning process retains the core spirit and skills of MI and builds on the prior processes of engaging, focusing, and evoking.
Strengthening commitment • Developing a plan is not a final but a beginning step. • Implementation intentions involve both a specific plan and the intention or commitment to carry
it out. • The clinical style of MI can help to strengthen commitment to a change plan. • Public commitment, social support, and self-monitoring can also reinforce the best of intentions.
Supporting change • The core style of MI can be useful throughout the implementation of change as, for example, in
supporting persistence. • Integrated MI involves flexible revisiting of the processes of planning, evoking, focusing, and
engaging as needed. • MI combines well with a variety of other treatment approaches and may enhance retention and
adherence.