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MI Counseling Strategies

The following includes some of the strategies used in motivational interviewing. This text is adapted and excerpted from Ingersoll, Wagner & Gharib (2000) and Rosengren & Wagner, (2001).

Motivational Counseling Strategies

Reviewing a Typical Day
Here, the counselor builds rapport while gathering information. The counselor avoids a focus on "problem behaviors," focusing instead on how substance use fits in to the person's life. Rollnick et al. (1992) suggest starting with, "Can we spend the next 5-10 minutes going through a day from beginning to end. What happened, how did you feel, and where did your use of xxx fit in? Let's start at the beginning." (P. 30). Proceed to help the client tell a story of the day, focusing on feelings and behaviors. If the client is receptive, summarize, then move to the next strategy.

Looking Back
This strategy simply involves engaging in a conversation with the client about what life was like "before." Before substance use problems, before legal, work or relationship difficulties, etc. What does the client remember? What good memories, hopes, dreams or plans did the person once have? What successes, achievements did the person have? If the person's history is very negative, it may still be useful to explore "what it was like," not necessarily in an attempt to process or resolve issues from that time, but primarily to establish the situation that existed before substance problems.

These techniques can be spurred by a client comment such as, "I used to have it all" or "I wasn't always this way." This is a natural segue for a therapist comment and question, "So things have really changed. Tell me a little bit about what life was like back then." Then the therapist uses OARS to keep momentum going and to elicit how the problem behavior fit into this circumstance and/or how it changed over time. For example, if drinking is the client issue, then, "So I'm wondering how your drinking fit in back then." Then later, the therapist might ask, "It sounds like your drinking changed over time. Tell me about that."

Then, you can explore how the client's path went from those previous dreams, plans successes or stressors into occasional, regular or chronic substance use. Again, the goal is not "insight" into deep psychological processes, just an establishment of some history to help "ground" the client as those with substance problems often seem caught in the "here and now" and sometimes seem to have lost a deep sense of self, of who they feel they are. The goal is for the client to obtain some perspective from the immediacy of his or her circumstance and to observe either how things have changed over time.

Good Things and Less Good Things
This strategy is simply to review what is "good" about substance use alongside a review of what is "not-so-good" about the use of substances. Steve Rollnick developed this phrasing for a particular purpose; namely, he wanted to avoid labeling a behavior as a problem when the client was not using that language. Failure to do this may lead to arguments with clients where they state adamantly the behavior is not a problem. Conversely, clients are often willing to acknowledge that there are less good things about a behavior. behavior. The technique also provides the therapist an opportunity to explore what "positives" may be sustaining a behavior. This is often a very fruitful inquiry and typically quite surprising to clients. They are often confronted with why they need to change a behavior, but only rarely asked what benefits they are receiving. This often serves to reduce resistance and allows inquiry into the Less Good things to be more acceptable to the client. We start this technique with a prefacing comment, then follow with a question about the Good Things. We follow up until all the Good Things have been exhausted. We summarize, then ask about the Less Good Things. These are then explored in more detail with requests made for examples of Less Good behavior. For example, "You said that your use had affected your children. Tell me about a time that happened." Once this area is fully explored, we summarize, emphasize any change talk that emerged, and then ask the client what their take on this material might be. The most important part of this strategy is to avoid labeling things as a problem.

Some counselors have begun using an alternate focus for the exploration of "good things and not-so-good things" - asking clients to talk about their experiences at AA or NA meetings and considering both "pros" of attending as well as "cons." The goal is to engage the client in sharing both likes and dislikes with the intention of reducing resistance or unhappiness about attending these meetings by "getting things out in the air." Often, people are more willing to accept the "good things" about meetings if their counselor explores and gives respect to what clients see as the "not-so-good" things.

Discussing the Stages of Change
Below is an example of how a counselor might talk with a client about the stages of change. After an explanation such as the one below (or something briefer!), the counselor might ask the client to react to the explanation just given about the stages of change. The counselor might ask the client to think about things they have changed in the past, and examples of when they were in the various stages of change during this process. If a client previously got stuck in a stage, ask the person to think about what methods they were using during that stage, if he or she can identify any. Write these down as well. Spend some time discussing the client's experiences with change, and consider focusing more on "less threatening" changes such as diet, adhering to medical advice, cigarette smoking, work habits, exercise, rather than on drug and alcohol abuse. This can reduce defensiveness about drug and alcohol in later sessions and help to teach how changing addictive behaviors is similar to making other changes.

One way a counselor might introduce the topic:
In or out of treatment, people seem to pass through similar stages as they work on making changes. This goes for many kinds of changes. The same stages seem to apply to people who want to lose weight as they do to people who want to cut down or stop their drinking or drugging.
The first stage of change is called the "Pre-contemplation Stage". During this stage people are not thinking about making a change. This may be because they have never thought much about their situation or they have already thought things through and decided not to change their behavior. Sometimes people may want to change, but not feel as if they could successfully make the change they desire. People in this stage might find it useful to get more information about their situation.
When people start thinking about their situation, they begin the second stage called the "Contemplation Stage." During this stage, people are "unsure" about what to do. There are both good and not-so-good things about their present situation. People in this stage also struggles with the good and not-so-good things that might come with change. During this stage people often both want change and yet want to stay the same at the same time. This can be a bit confusing for people as they feel torn between these options.
At some point, when people have been thinking through whether or not to change, they may come to feel that the reasons for change outweigh the reasons not to change. As this weight increases on the side of change, the person becomes more determined to do something. This is the beginning of the next stage, called the "Preparation Stage." During this stage, poeple begin thinking about how they can go about making the change they desire, making plans, and then taking some action toward stopping old behaviors and/or starting new, more productive behaviors. People often become more and more "ready" and committed to making changes.
During the next stage of change called the "Action Stage" people begin to implement their "change plans" and trying out new ways of being. Often, during this stage people let others know what's happening and look for support from them in making these changes.
Once people have succeeded in making and keeping some changes over a period of time they enter the "Maintenance Stage." During this stage, people try to sustain the changes that have been made and to prevent returning to their old ways. This is why this stage is also known as the "Holding Stage." Many times the person is able to keep up the changes made and then makes a permanent exit from the wheel (or spiral) of change. During this stage it is also common for people to have some "slips" or "lapses" where old habits return for a short time.
Sometimes people also have "relapses" which may last a longer period of time. When a person has a relapse, he or she typically returns to the precontemplation or contemplation stages. the person's task is to start around the wheel of change again rather than getting stuck. Keep in mind that relapses, slips, and lapses are normal as a person tries to change any long-standing habit. Often times people go around the wheel of change 3 or 4 (or more) times before permanent change takes hold.
There is some pretty good evidence that people shouldn't skip stages. Someone that jumps right into the action stage may not spend enough time preparing for change. The result is they have trouble in keeping the changes they've made. For this reason, it is important for you to know which stage you're in and what things you need to do to move to the next stage.

Assessment Feedback
Another strategy involves providing feedback to the client about their behavior. This can be formalized, as in the Drinker's Check-up discussed below, or informal based on information elicited during the course of the intervention. Normative feedback can include information about levels of use, consequences of use or comparison to others. Standardized instruments like the ASI, SASSI, AUDIT or DrInC or InDUC provide ready resources for this type of feedback. The comparison can be to others or within themselves on scales. For example, a therapist could use the DrInC scales to convey where the client acknowledges experiencing problems and where they seem to be doing fine. An informal feedback opportunity that frequent arises is tolerance. Clients often point to their ability to "hold" alcohol as a sign there is not a problem. This statement allows the therapist to offer information about how tolerance operates, including the potential detrimental effects of circumventing this early warning system. Feedback can also be from locally used instruments or information gathered in the session. For example, in exploring HIV risk behavior, on emight elicit information about values, goals and sexual practices and then review with clients the information they shared, including any inconsistencies observed. They then explore together these inconsistencies. The most important point here is the therapist acts simply as a conduit for information. The client is given the job of ascribing meaning. An example of informal feedback might go like this:

Mary, would it be okay if I offered a little information to you based on what we've talked about so far? Correct me if I'm wrong about anything. To begin, it sounds like you've noticed an escalating pattern in your cocaine use. This is a source of some concern to you both because of your parents' history of substance misuse and because you've begun to drop away from your old friends. You're spending a lot more time recovering from the use and the financial drain has begun to create some issues with your husband. You've also noticed the high has changed and your using more to get to that place you want. Finally, you are concerned about your relationship with your kids. You swore that you were going to be a better mom to your kids than your mom was to you, but now your not so sure how you've done with that. I'm wondering what you make of all this?

Values Exploration
A values focus can help a person define his or her "ideal self" by exploring those behavioral ideals to which the person resonates. Sometimes, individuals have forgotten about these values or have rejected them as naive or unachievable. Simply focusing on these ideals can help open a person detect actual behaviors inconsistent with the ideal.

A focus on values may stimulate motivation for change. Focusing on discrepancies between ideal life conditions and actual conditions may induce a desire to "recalibrate" daily behaviors to be more congruent with deeply held beliefs. Awakened to a deeper sense of self and values, the person may become increasingly aware that the problematic behaviors meet certain short-term needs but do not lead to fulfillment of higher values or long-term satisfaction. Focusing on ideals can help decrease clients' defensiveness and increase desire for change by shifting the focus away from consideration of "bad" behaviors or lifestyle, toward a focus on a more deeply satisfying lifestyle that can be pursued and enjoyed. Clients may come to perceive that they do not necessarily have to purge valued aspects of their current self; instead they need to restrain certain tendencies in order to develop a deeper, more aware self and live with a greater sense of purpose (importance) and power (confidence).

Ambivalence about various possibilities can be viewed in part as the experiential result of multiple conflicting values. While ambivalence may be resolved from concluding that longer-term values (for example, stable job, good family and friend relationships, ownership of property) take precedence over short-term values (for example, fun, relief from stress or anxiety, excitement), there are other paths to its resolution. Sometimes, it is not so much a conflict between the long- and short-term values themselves but an issue that the strategies for fulfilling short-term values are precisely those strategies that prevent fulfilling the longer-term values. There are other ways to gain excitement other than using cocaine and living a fast lifestyle. By seeking with the client the positive motivations behind the problem behaviors, we can open the door to consideration of alternative behaviors that address short-term needs without unduly interfering with the pursuit of long-term goals.

In addition to a general discussion of the client's values, counselors can use a set of values cards and have the client sort through the cards and order them in accordance with his or her priorities. Topics discussed may include the meaning of the various values statements, evaluation of current consistency between values and behavior, perceived barriers to and opportunities for increasing value-behavior consistency, and personal evaluation of the extent to which the use of substances plays a role in achieving or preventing consistency. Counselors sometimes report that this technique increased the ease of practice as well as client engagement.

One study of individuals who have made "quantum" changes shows the dramatic shifts in values that individuals can undergo in a very brief timeframe.

Looking Forward
Looking Forward has a similar focus to Looking Back. It has the client envision two futures. The first is if they continue on the same path without any changes where they might be five or ten years from now. The second future is if - and the emphasis is on if - they decided to make a change in their behavior, what that future might look like. The therapist's job is not argue one position or another, but rather just elicit the information and then ask the client to comment on these imaginings.

Exploring Importance and Confidence
A recent strategy developed by Rollnick and colleagues (Rollnick, Mason, & Butler, 1999) involves the dimensions of importance and confidence. This strategy essentially explores the client's impressions of how important is to make a change and how confident he or she is that he or she can succeed in changing. The therapist explores the client's impressions of what it is that makes the change important, how this change fits in with other aspects of his or her life, and what events may transpire to make this change seem more important than it currently does. The issues around a person's confidence in changing are explored in a similar way, and the therapist may guide the client to review past change attempts and determine how the therapist and significant others could help the person succeed in making a change.

Decisional Balance
The decisional balance exercise is a values exercise similar to good things/less good things, except with a focus on future behavior. Counselors ask clients to identify the anticipated "pros" and "cons" of changing a behavior, then compare this with the pros and cons of not changing the behavior. Once the pros and cons have been identified, counselors may ask clients to consider which of these options best meet clients' ideals while also tending to their preferences for experiences. Counselors may reflect that clients have the opportunity to create different lifestyles and to choose in part who they will become in the future through the course of action they choose.

As with a number of these strategies, this one can be done on paper as preparation for or a supplement to a conversational approach.

Change Planning
A change plan is a technique that can be quite helpful with clients that are ready to do this type of work. To avoid a premature focus on action plans, some have taken to calling these forms, "The Next 90 days." This form can then be used to record any number of actions including simply thinking more about an issue. This form typically includes just a few simple questions (Fill in), which the therapist and client fill in conjointly.

Do it All in a Moment or Two
One counselor, Chris Dunn, has offered what he calls the 20-second MI intervention. Apparently, there are also colleagues at Kaiser-Permanente in Portland who are doing similar work. The basic premise is you have a very brief amount of time and a potentially thorny issue to solve. Chris simply clicks through an acronym-based model called FRAMES and leaves the client with the responsibility for making a choice. For example:
So, Bill you are in your third week of treatment and your feeling like you've accomplished everything you need to (FEEDBACK). My sense is you've begun exploring what's led to your drinking (FEEDBACK). I am concerned that you've not spent much time thinking about how you'll handle your homelife (FEEDBACK). If you asked for my advice, I would recommend you stick with treatment a little longer and work on this area (ADVICE). However, there may be other ways to do this (MENU OF OPTIONS) and the choice is really yours to make (RESPONSIBILITY). I know you've been feeling antsy (EMPATHY) and I have faith that you can make a good decision (SELF-EFFICACY). What do you think?

Monitoring the effectiveness of your use of MI Strategies
Although formal research methods for client outcomes are a worthwhile goal, this is unlikely to be available for many clinicians. A much more practical method is available for practitioners: observe your clients. If during the session they are constantly arguing, disagreeing or ignoring you, then what you are doing is not working. It's a signal that you should shift methods. Even if you convince them of the folly of their ways, change is unlikely to be sustained under these circumstances. If clients agree to do something between sessions, then fail to do it, this does not necessarily mean there is a problem. It may simply be ambivalence. However, if it happens consistently, then you may be arguing for change and the client is simply acquiescing. It is time to focus on listening to your client. Finally, if your client's don't return for sessions, it may be a sign that they are giving up you rather than the problem behavior. You may have pressed too hard for a change the client was not ready to make. Our advice: pay attention to your clients, they tell you one way or another how you are doing.

 

Reference: Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.