MODULE 1:
ENHANCING MOTIVATION 
FOR CHANGE

MODULE 1
ENHANCING MOTIVATION
FOR CHANGE

Table Of Contents

TABLE OF CONTENTS…………………………………………………………………………	II
MODULE 1: ENCHANDING MOTIVATION FOR CHANGE…………………………….........	1

	MOTIVITIONAL INTERVIEWING AND STAGES OF CHANGE……………………………................................	1
	THE SPIRIT OF MOTIVATIONAL INTERVIEWING…………………………………………................................	1
1.	Collaboration………………………………………………………………………………......................................  	2
2.	Evocation……………………………………………………………………………………………………………….. 	2
3.	Autonomy………………………………………………………………………………………………………………….	2
THE PRINCIPLES OF MOTIVATIONAL INTERVIEWING………………………………………………………..	2
1.	Express empathy……………………………………………………………………………………………………….	2
2.	Develop discrepancy………………………………………………………………………………………………….	2
3.	Roll with resistance…………………………………………………………………………………………………….	2
4.	Support self-efficacy…………………………………………………………………………………………………...	3
FIVE EARLY METHODS FOR MOTIVATIONAL INTERVIEWING………………………………………………	3
1.	Ask open questions……………………………………………………………………………………………………..	3
2.	Listen reflectively……………………………………………………………………………………………………….	3
Reflection as a directive tool…………………………………………………………………………	4
Types of reflections………………………………………………………………………………….	4
3.	Affirm…………………………………………………………………………………………………………………….	5
4.	Summarize………………………………………………………………………………………………………………..	5
5.	Elicit change talk………………………………………………………………………………………………………...	6
RESISTANCE…………………………………………………………………………………………………………	6
		Handling resistance……………………………………………………………………………….......................................	7
		Using reflection to diffuse resistance………………………………………………………………………………………	7
                  Using strategic responses to diffuse resistance…………………………………………………………………………….	9

THE INITIAL SESSION……………………………………………………………………………….. 11

INTRODUCTION……………………………............................................................................................................... ..	11
	SET THE AGENDA……………………………………………………………………………………………………..	11
	REVIEW CONFIDENTIALITY…………………………………………………………………………………………	12
	UNDERSTANDING THE PROBLEM………………………………………………………………………………….	12
		1. Ask open-ended questions………………………………………………………………………………………………….. 12
		    Disadvantages of Status Quo…………………………………………………………………………………….	13
		    Advantage of Change…………………………………………………………………………………………….	13
		    Optimism about Change …………………………………………………………………………………………13
                      Intention to change ………………………………………………………………………………………………13
		2. Use reflective listening……………………………………………………………………………………………………...	13
		3. Affirm the client ……………………………………………………………………………………………………………..	14
		4. Summarize……………………………………………………………………………………………………….	……………14
TROUBLESHOOTING………………………………………………………………………………………………….	15
TRANSITION TO DISCUSSING TREATMENT………………………………………………………………………	15
DISCUSS THE STRUCTURE AND GOALS OF THE TREATMENT………………………………………………..	16
COMPLETE AGENCY SPECFIC TASKS……………………………………………………………………………..	16
SUMMARIZE SESSION ……………………………………………………………………………………………….	16
PREVIEW NEXT SESSION…………………………………………………………………………………………….	17
REVIEW HOME ASSIGNMENT……………………………………………………………………………………….	17
END SESSION…………………………………………………………………………………………………………...	17

REFERENCES …………………………………………………………………………………………..	18

APPENDIX A: SESSION MATERIALS ………………………………………………………………	19

DECISIONAL BALANCE WORKSHEET ……………………………........................................................................	20
MODULE 1 SESSION CHECKLIST…………………………………………………………………………………...	21

Module 1: Enhancing motivation for change

Motivational Interviewing and stages of change

Motivational Interviewing (MI) is a client-centered, directive counseling approach designed to help resolve ambivalence and enhance intrinsic motivation for changing problem behaviors (Miller and Rollnick, 2002).  MI is designed to facilitate the processes of natural change by helping people to resolve ambivalence an progress through the stages of change outlined by Prochaska and DiClemente (1983).  According to later formulations of this model (Prochaska, DiClemente (1983).  According to later formulations of this model (Prochaska, DiClemente, & Norcross, 1992), behavior change is represented by six distinct stages (precontemplation, contemplation, preparation, action, maintenance, and relapse) that characterize the individual’s motivation for change.  Precontemplation is the first stage in this model.  In Precontemplation the          

Stages of change
(Prochaska, DiClemente & Norcross, 1992)

Stages of Change

Prochaska, DiClemente and Norcross, 1992

Entry into precontemplation into contemplation into preparation into action intomaintenance into permanent exit or into relapse into precontemplation and repeat

individual does not recognize the behavior as problematic and may see no significant reason for change.  The Contemplation stage is characterized by consideration of both the problem behavior and the feasibility of changing that behavior.  Individuals in the Preparation stage begin some decision-making and may start preparing themselves for initiating some behavior change.  The Action stage begins when individuals start to modify the problem behavior.  The Maintenance stage is characterized by sustained change of the problem behavior.  Movement through the stages is neither linear, nor uni-directional.  For example, an individual in the
stage of Preparation may move on to Action, but also may fall back into Contemplation.  An individual in the stage of Contemplation may move on to Preparation but in some cases may move directly to Action.  An individual may pass through variations of these stages many times over the course of their recovery.  MI is intended to help individuals move through the stages of change by directively exploring and resolving ambivalence about changing problematic behavior.  MI interventions are useful for building motivation for change in the early stages and for strengthening commitment to change during the Preparation stage.

The spirit of Motivational Interviewing
Miller and Rollnick (2002) describe MI as a way of “being with people” that is represented by the following three characteristics:

1.	Collaboration
MI is characterized by a relationship between the therapist and client that is a working partnership rather than a relationship in which the therapist holds power and authority over the client.  The therapist creates a non-coercive environment that is respectful of the client’s perspective and experiences.

2.	Evocation
It is ultimately the client’s responsibility to make an argument for why changing a problem behavior is in their best interest.  The therapist’s job is to help the client make this argument for change by eliciting thoughts about change.

3.	Autonomy
Therapists practicing MI must fully respect the client’s personal choice even if it contradicts therapeutic convention.  The therapist may act to help the client make an informed choice, but the ultimate responsibility for choosing and implementing change lies with the client.

These three characteristics embody the MI style or “spirit” of interacting with clients.  More than the use of any specific strategies or techniques, therapists should strive to embody this spirit as an overriding feature of their work with clients.  Although the individual skills-based modules in this manual are derived from a range of approaches, the spirit of MI can be successfully adapted and applied to each of these modules.

The principles of Motivational Interviewing
Miller and Rollnick (2002) describe four broad principles that underlie the practice of motivational interviewing:

1.	Express empathy
A fundamental part of the style of MI is understanding and accepting clients as they are without judgment or criticism.  Through client-centered reflective listening, the therapist seeks to understand the client and express this understanding with accurate empathy.  The therapist may not agree with the client’s thoughts or perspectives, and may respectfully present an alternative view, but maintaining acceptance for the client regardless of his or her beliefs and choices is essential to MI.

2.	Develop discrepancy
One of the primary goals of MI is to help clients resolve ambivalence about changing a problem behavior and engage in some course for meaningful change.  Through the use of directive questions and reflections, the therapist can guide the client to a recognition of discrepancies between current behavior and larger goals, values, and life plans.  This strategy is aimed at creating an internal drive for change.

3.	Roll with resistance
A central tenant of MI is that “client resistance” is not a trait or characteristic of the client, rather it is a behavior that is evoked by others.  For the client to exhibit resistance, there must be something to resist (e.g., pressure from family or friends to change, therapist imposing something the client does not want).  It is the client, not the therapist who must make an argument for change.  Clients who have ambivalence about changing a problem behavior are more likely to be persuaded to change by their own argument than by another person’s argument.  In some instances, therapists making a strong argument for change may invoke the opposite behavior than what is intended; that is, clients may take up the counter argument (i.e., why not to change).  When resistance is encountered within MI it is not opposed or challenged.  This resistance is often a sign of dissonant goals between the therapist and the client and may signal a need for the therapist to shift course.

4.	Support self-efficacy
An important aspect of facilitating change using MI is to help clients believe that they have the ability to change.  The belief clients have in their ability to change (self-efficacy) is instrumental for initiation of change.  Without self-efficacy the client may not perceive any point to attempting change.  The therapist’s role in supporting self efficacy is to maintain the belief that clients have the capacity for change, and to support the clients’ belief in themselves as being capable of change.

Five early methods for Motivational Interviewing
Miller and Rollnick (2002) describe five methods that are useful in the first session of MI.  The methods are 1) ask open questions, 2) listen reflectively, 3) affirm the client, 4) summarize, and 5) elicit change talk.

1.	Ask open questions
Open-ended questions are intended to create a dialogue between the therapist and the client; they are qualitatively different from questions that are aimed at gathering specific pieces of information.  Closed questions often result in short and rapid answering, sometimes as simple as “yes” or “no.”  The consequence of closed questions can be the “question-answer trap” or the “expert trap.”  Some examples of open and closed questions follow:

CLOSED	“How much do you drink each day?”
OPEN		“What is your drinking pattern like?

CLOSED	“Have you been having any problems at work since you started using?”
OPEN		“What sorts of problems have you noticed since you started using?

CLOSED	“Would you consider going to detoxification?”
OPEN		“What would you like to do about your alcohol use?”

2.	Listen reflectively
Reflective listening is the primary tool used by the therapist to convey understanding, clarify meaning, express empathy, and elicit change talk.  This skill involves “listening carefully to what the client is saying and many times reflecting it back to the client in a slightly modified or reframed form.  The therapist may also acknowledge the client’s expressed or implicit feeling state” (Rogers, 1959).  This method of responding is thought to minimize defensiveness and encourage the client to further explore the topic, while also communicating respect and caring for the client.  It also helps to clarify what the client means and selectively reinforce certain ideas expressed by the client (COMBINE, page 22).  Reflective listening is a means of checking the meaning of the client’s narrative while moving the discussion forward.

Reflection as a directive tool
Reflection encourages clients to further explore and elaborate on the ideas reflected by the therapist.  With the goal of encouraging clients to talk about change, the selection of what content to reflect from a client narrative is one means by which therapists are able to be directive in encouraging change talk.  Consider the following example:

Client:		“I have been worried about my liver for a long time but each time I see my 
		Dr. for a checkup, it seems to be fine.  Sometimes I think I’m immune to
		cirrhosis.  Given how I’ve been drinking, It’s surprising I’m still alive.”
Therapist:	“Even though your liver function tests keep coming back normal, you still
		are worried.”
Client:		“Each time I see my Dr. I’m convinced it will be bad news.  Sometimes I 
		wonder if some bad news would be what I need to really make a change.”
Therapist:	“The possibility of having liver disease is frightening enough that you 
		think you could stop drinking if you had it.”
Client:		“That’s the madness of it all.  I sometimes think being sick would be good 
		for me.”
Therapist: 	“You want to stop drinking so much that you would almost be willing to 
		sacrifice your health to get there.”

In this example, the therapist selectively reflects the client’s change talk and does not become distracted by the details of liver testing or the belief in an immunity to disease.  While these topics are potentially interesting, the goal is to use reflection to elicit change talk.  In this case, the most salient change talk is the concern the client expresses about his potential for developing liver disease.

Types of reflections

Simple
Simple reflections are used to convey understanding and empathy while moving the client narrative in the direction of change statements.  They add little in the way of additional meaning but capture the client’s intended meaning.  Simple reflections are not a “parroting” of the client narrative but rather the therapist’s best guess of the client’s meaning formulated in their own words.

Therapist:	“What else concerns you about your drinking?”
Client:		“Sometimes I don’t get to work on Monday because I’m too sick from
		drinking all weekend and my boss has called me on it a few times.”
Therapist:	“So your boss is noticing the effects of your drinking on your attendance.”

Client:		“I can’t afford to lose this job, my wife is out of work right now so money 
		is tight.”
Therapist: 	“You see the possibility that you could lose your job because of drinking.”

Complex
Complex reflections capture the client meaning and go beyond this to include some emphasis or additional meaning that represents a deeper understanding of the client than a simple reflection might.  Complex reflections often include some recognition of the client’s affect.  There are several types of complex reflections including double-sided and amplified (see “handling resistance” for examples).

Therapist: 	“What else concerns you about your drinking?”
Client:		“Sometimes I don’t get to work on Monday because I’m too sick from 
		Drinking all weekend and my boss has called me on it a few times.”
Therapist:	“You are worried about what your boss may do if you keep missing
		Mondays.”
Client:		“I can’t afford to lose this job, my wife is out of work right now so money
		is tight.”
Therapist: 	“You are worried that drinking will keep you from being able to provide 
		for your family.”

3.	Affirm
Affirming the client can be a useful tool in helping to build rapport.  The therapist seeks opportunities praise or compliment the client.  Affirmation is used to reinforce the client’s self-motivational statements, stated intentions to change, and evidence of change.  Affirmations enhance the client’s sense of control and responsibility for changes, and boosts the client’s self-confidence in making difficult changes.

“I appreciate the time you have taken to work on this.”
“I think it’s great that you want to do something before it gets worse.”
“I really respect the steps you’ve taken to stop using alcohol.”
“You’ve been through a lot; I admire your commitment to making these changes.”

4.	Summarize
MI therapists use periodic brief summaries to demonstrate understanding of the client while also allowing the client a chance to hear their own narrative reflected back in the therapist’s words.  Periodic summaries may be particularly helpful for people with serious mental disorders including thought disorders.  These summaries can serve as a collection of things that the client has discussed.  When used in this manner, the means of linking information that has been gathered over separate time periods.  Used as a directive tool, a linking summary may help the client to reflect on the relationship between the information discussed at different times which reflect some discrepancy.  A transitional summary is used as a means for transitioning from one phase of treatment to another, or from one task to another within a session.  This summary can also be used 

as a tool for ending sessions with a full account of what the therapist has come to understand about the client.

5.	Elicit change talk
One of the primary goals of MI is to build client motivation for change by placing the client in the position of making an argument for change.  In a non-conformational manner, the therapist uses directive questions and reflection to guide the client toward verbalization of reasons for change.  Miller and Rollnick (2002) identified the following four categories of client change talk:

Disadvantages of the status Quo – Statements that reflect an understanding of the continued problems associated with substance use.

“I am bound to lose my job eventually if I keep this up.”
“I can’t afford to do this anymore, I may lose my housing if I don’t catch up with rent.”
“This has gotten to be more of a problem than I ever thought.”
“I’m not sure how bad it will get if I keep on using.”

Advantages of change- Statements that reflect recognition of positive aspects of change.

“I know that I will feel better about myself if I can do something about this.”
“Things will be better with my family if I can stop drinking so much.”
“I’m hoping to lose some weight once I stop drinking.”
“It will be such a relief to not worry about getting caught.”

Optimism about Change- Statements that speak to the client’s self-efficacy, or belief in the ability to make changes.

“I know I can do this.”
“This should not be hard for me, I just need to…”
“This something I can do.”
“I’m going to get through this.”

Intention to Change- Statements that reflect some commitment to initiating change.

“I want to do something about this now.”
“I would like to leave all this behind and never look back.”
“Making this change will feel good to me.”
“I’m eager to get started with this.”

Resistance
Resistance is a popular concept within psychotherapy that is characterized as a reluctance on the client’s part to adopt change.  The reluctance is often described as a client characteristic (“resistant client”) or a client behavior (“client is resisting change”).  In contrast, resistance in an MI framework is seen as the result of an interaction between people; it can only occur in the context of a relationship.  Resistance in treatment is usually due to therapist and client having different agendas or goals within a session.  Resistance is also evoked in relationships other than the client-therapist.  For instance, a client attending treatment under threat from family or courts may initially display a host of resistance behaviors that bear no connection to the relationship with the therapist.

The interaction between therapist and client can be characterized on  a continuum between consonance and dissonance as seen below:

Consonance								Dissonance
Working with								Working against
one another, a								one another,
common goal								different agendas

Consonance is characterized by a mutual effort moving in the same direction, having the same desire or goal.  Dissonance is characterized as the client and therapist working against one another or in different directions.  A dissonant interaction between the client and therapist is often what many describe as resistance.

Dissonance may emerge when: 1) there is a mismatch in the objectives of the therapist and the client, 2) the therapist and client are attempting to talk about fundamentally different problems, or 3) there is a mismatch in stage of change of the client and the therapist’s perception of the client’s stage of change.

Dissonance is usually easy to recognize during an interaction with a client.  The client may begin to interrupt, talk over, challenge, discount, disagree with, or express hostility toward the therapist.  Clients may also just stop coming to therapy.  Since dissonance is evoked by the interaction, it follows that it can be reduced or eliminated by altering the interaction.

Handling resistance
Understanding that resistance occurs within the context of an interaction is the most important concept to understand if the therapist is to effectively diffuse resistance.  Just as the therapist’s style of interaction can elicit resistance, so too it can diffuse resistance.  For some client’s, resistant behavior may simply be a means for expressing their ambivalence about change.  Exploring this ambivalence with a non-confrontive  and accepting approach may help the client to understand and possibly resolve the inner conflict related to change.  One of the primary tools for handling resistance is the use of reflective listening.

Using reflection to diffuse resistance

Simple reflections are used to give the client the sense that the therapist understands the conflict they are experiencing without attempting to change or convince the client of anything.

Client:		“If I stopped drinking, I don’t think life would be any fun.”
Therapist:	“You would have a lot less fun without alcohol.”

Amplified reflections are used to slightly exaggerate the content of what the client is expressing in a manner that places the client in the position making an argument for change.  As with simple reflections, an amplified reflection is a statement of understanding and contains no judgment or bias.  In many cases, slightly overstating what the client has expressed places the client in a position of correcting the therapist’s misperception, a process that involves the client using change talk in the correction.

Client:		“If I stopped drinking, I don’t think life would be any fun.”
Therapist:	“Without drinking, there is no pleasure in life.”

In this example, an MI-inconsistent therapist response would be to question the reality of the client’s assertion that drinking is the only possible pleasure in life.  The goal of this challenge would be to help the client alter a belief the therapist views as faulty.  This righting reflex may have the opposite effect and lead the client to defend the position that pleasure can only be achieved through drinking.  Alternatively, the amplified reflection (above) slightly overstates the client’s assertion and leaves the client in a position to take up the opposite argument.  In effect, placing the client in the position of making the case for change:

Client: 	“I wouldn’t say no pleasure, I would just be pressed to find ways to have 
		fun if I couldn’t drink.”

Amplified reflections should be used sparingly and only when the slight amplification is a plausible mis-understanding.  Misuse, overuse, or improper use may sound to the client more like sarcasm than a reflection of what you understand.  The emphasis used can dramatically alter the meaning.

Consider the same example phrased as a question instead of a reflection or with the emphasis on NO:

“Without drinking, there is no pleasure in life?
“Without drinking, there is no pleasure in life.”

Double-sided reflections are used to simultaneously reflect both sides of the internal conflict the client is experiencing.  Double-sided reflections join two opposing client thoughts in a single reflection that acknowledges the client’s ambivalence in a respectful and non-judgmental manner.  The joining of two opposing thoughts about change may help clients further explore their ambivalence.  Double-sided reflections rarely evoke further resistance as the therapist has not taken up one side of the conflict.

Client: 	“If I stopped drinking, I don’t think life would be any fun.”	
Therapist:	“So, on one hand, you are not sure you want to give up the pleasure that 
		you get from drinking, but on the other hand you worry about what might 
		happen at work if you don’t make some changes.”

Using strategic responses to diffuse resistance
Sometimes the use of strategic responses will help to diffuse resistant behavior.

Shifting focus is a strategy in which the therapist may move the discussion in a different direction and simply bypass the resistance.

Client:		“The only reason I came here is to get my husband to stop harassing 
		me about my drinking.  I know that you are going tell me the same thing 
		that he keeps telling me, that I’m an alcoholic and I need to quit drinking.  
		Let me tell you right now, that’s not going to happen.”
Therapist:	“I won’t be able to tell you what to do, that will be something you have to 
		decide.  I would like to learn more about you and help you to make the 
		decision that is right for you.  Let’s start by talking about what led up to
		you coming in for this appointment.”

Reframing is a strategy in which the therapist slightly changes the meaning of what is being discussed in a way that allows the client to see something within a new perspective.

Client:		“The only reason I came here is to get my husband to stop harassing me
		about my drinking.  I get mad every time he asks me how much I’ve had 
		and then we go at it.  I feel like drinking more after we talk.”
Therapist:	“It sounds like he is worried about how much you’re drinking but his way
		of showing this concern feels more like nagging to you than support.”

Agreement with a twist is a strategy in which the therapist accurately reflects the resistance expressed but then adds a reframe to slightly change the meaning.

Client:		“The only reason I came here is to get my husband to stop harassing me
		about my drinking.  I get mad every time he asks me how much I’ve had 
		and then we go at it.  I feel like drinking more after we talk.”
Therapist:	“You are tired of being questioned and having to deal with the fight that 
		follows.  It sounds like his way of trying to help you is in fact not very 
		helpful.”

Emphasizing personal control is a strategy used by the therapist to explicitly affirm that the client is in control and has the choice about whether to change

Client: 	“The only reason I came here is to get my husband to stop harassing me
		About my drinking.  I know that you are going tell me the same thing that
		he keeps telling me, that I’m an alcoholic and I need to quit drinking.  Let
		me tell you right now, that’s not going to happen.”
Therapist:   	“You will have to decide for yourself what is best.  Nobody can make that
		decision for you including me.”

The Initial Session

The primary objectives of this initial session are to: 1) develop rapport with the client, 2) develop an empathic understanding of the client’s concerns about the dilemma of change, 3) to enhance the client’s intrinsic motivation for changing substance use, and 4) to complete necessary agency paperwork.

=====╣Module Outline╠===========================================

Target discussion points:

	Introduction
	Set the agenda
	Review confidentiality
	Understanding the problem
	Summarize clients concerns
	Complete agency-specific tasks
	Review treatment structure and goals
	Summarize session
	Preview coming session
	Discuss home assignment
	End session
===============================================================

Although the session includes optional exercises for enhancing motivation, use of these exercises is encouraged only when there is a clear clinical need for additional work on enhancing motivation.

Introduction
The therapist should conduct a very brief professional introduction and review confidentiality.  Details regarding the structure, length, and goals of treatment are reviewed after the therapist begins to understand the client’s reasons for seeking treatment.  However, if the client requests information on these details, the therapist should engage in the discussion.

Set the agenda
After addressing any questions or concerns from the introduction, the therapist should discuss the agenda for the session which includes: 1) understand the client’s concerns about substance use, 2) complete agency-related tasks, and 3) discuss the structure and details of the treatment.

“I’m happy to get started with you today.  We are going to meet for about an hour.  My main goal is to understand what has brought you here.  I would like to understand what your thoughts are related to your substance use.  I want to be sure that I fully understand any concerns you might have.”

“I would also like to take time today to collect some information that I need for my agency.  After we have completed this, we can talk about what this treatment may have to offer you, how long we will meet, and other general details about the treatment that you would like to know.  How does this sound to you?”

Review confidentiality
The therapist should explain the limits of confidentiality and answer any questions or concerns the client may have.

	“I’d like to remind you about confidentiality.  What you tell me is protected from 		being released to anybody unless you request that it is shared and sign a release 		form.  The only exception to confidentiality is if I have reason to believe that you 		might be at risk for hurting yourself or somebody else.  In that case, protecting 		you or the other person is more important than protecting confidentiality.”

	“Do you have any questions about confidentiality?”

Understanding the problem
In the early phase of treatment, the goal is to allow the client to explore concerns about substance use in an open and accepting atmosphere.  The five early methods outlined by Miller and Rollnick (2002) encompass most of what the therapist should be doing in the first half of this session.

1.	Ask open-ended questions
After discussing the goals of the session, the therapist begins with some open-ended questions that are intended to elicit change talk.  Some examples of open-ended questions in the initial portion of session include general open-ended questions and targeted open-ended questions.

General open-ended questions provide few boundaries on the content or scope of what you are asking the client.  These sometimes lead clients to off-topic dialogue.  Re-direction with targeted open-ended questions may be useful if clients diverge far from the topic of substance use.  Some examples of general open-ended questions include:

“What led up to you enrolling in this treatment?”

“Tell me a little about why you are here today?”

Targeted open-ended questions are not intended to elicit specific points of information (e.g., patient history) but rather intended to elicit specific types of change talk.  These evocative open-ended questions can be composed in a manner to elicit specific types of change talk.

Disadvantages of Status Quo

“Why is it important that you make some sort of change?”
“If you didn’t make any changes in your cocaine use, what would be the not-so good things that might happen?”
“What concerns do you have about your heroin use?”
“What are the risks of not changing?”

Advantages of Change

“What do you want to see happen by changing your alcohol use?”
“If you decided to change your cocaine use and you were successful at it, what positive changes in your life would you want?”

Optimism about Change

“What gives you some confidence that you can do this?”
“If you decided to make a change, what strengths or resources do you have that will help you succeed?”

Intention to change

“What do you think you want to do about this?”
“What do you want to do to get started making a change?”
“How do you proceed form here?”
“What course of action do you want to take?”

2.	Use reflective listening
When exploring the nature of the problem and eliciting change talk, one of the therapist’s tools for being directive is the use of reflective statements.  The therapist’s job is to listen closely to the client’s narrative and formulate reflections that convey an accurate and empathic understanding of the client.  Within the client’s narrative the therapist is looking for statements that reflect change talk and ambivalence about change.  Below is a sample dialogue of reflective listening.

Therapist:  “What led up to you enrolling in this treatment?”
Client:	      “My Dr. gave me your number and said I should call.”
Therapist:  “Your Dr. is concerned about your drinking.”
Client:	      “I took this test and they said my drinking is risky.”
Therapist:  “Something about your drinking was out of the ordinary.”
Client:	       “ I don’t drink much, but I do drink everyday; they think that is a problem.”
Therapist:  “You are not so sure it a problem.”
Client:	      “I may drink more often than some people, but it’s not like I’m falling down 
	       drunk all the time.”
Therapist:  “You see that drinking as often as you do is not normal.”
Client:       “I do, but I’ve always tried to keep myself from drinking more and have been
	       able maintain like this for a long time.”
Therapist:  “You are worried that if you drank more you might end up falling down drunk 
	       sometime down the road.”

Clients may not be aware of the risks, or concerned about the potential consequences, of heavy substance use.  In this next example the client is coming in with some resistance that was elicited by his case manager.  Note that the therapist used questions sparingly.  Simple reflections and a single amplified reflection help this dialog move from the client being reluctant to see his case manager’s reason for referral to recognizing some intrinsic need for change.

Therapist:  “What led up to you enrolling in this treatment?”
Client: 	“My case manager said I should do this, she thinks I drink more than I 
	      should.”
Therapist:  “She is worried about how much you drink.”
Client:        “My drinking is nothing compared to some of the people I know, I’m not 
	        Even sure why I agreed to go through this.”
Therapist:  “You don’t see any need to make changes in your drinking, it’s not something
	       You that you have any concern over.”
Client:	       “I wouldn’t say I’m not at all concerned, I think she made me sound much 
	        Worse off than I see myself.”
Therapist:  “Her concerns aside, what worries you about your drinking?”		

3.	Affirm the client
An affirmation is when a therapist’s reflection reveals a recognition of change-oriented strengths, personal qualities, or efforts.  The therapists should seek opportunities to affirm the client in a genuine manner as a means of demonstrating respect toward the client, fostering collaboration, and supporting the client’s self-efficacy.

“I really appreciate how honest you have been with me today.  You felt as though your case manager pushed you into coming here but you seem to really be making the effort to help me understand your situation.”

“You’ve been though a lot; I admire your commitment to making these changes.”

4.	Summarize
The use of periodic brief summaries that incorporate self-motivational statements is a very important skill in MI.  Summaries allow therapists to collect together the clients’ change talk and present it back to them strategically (handing clients a “bouquet” of change talk).  Summaries also help therapists link together discrepant client statements the underscore client ambivalence expressed during the session.  Summaries also can 
convey a fuller understanding about what clients have said, giving them an opportunity to further elaborate or amend what they have said, or permitting therapists to transition to other important areas.  In general, summaries help organize and pace the discussion and deepen the therapist’s expressed empathy.  The example below illustrates the use of a periodic summary.

	“So your case manager is concerned about your drinking and she suggested you 
	come to see us.  You may not agree with her about how risky your drinking is or
	whether you even need to make a change at this point, but you do have some 
	concerns about the future and what might happen if your drinking gets worse 
	than it is today.”
 
As directive method for eliciting change talk and addressing ambivalence is for the therapist to use a summary reflection followed  by an evocative question.  This may encourage clients to further elaborate on their change potential.

“So your case manager is concerned about your drinking and she suggested you come see us.  You may not agree with her about how risky your drinking is or whether you even need to make a change at this point, but you do have some concerns about the future and what might happen if your drinking gets worse than it is today.  I’d like to understand what gives you the sense that it will become worse in the future?”

Troubleshooting
Some clients may have difficulty verbalizing their reasons or need for change not because of a reluctance to consider the need for change, but rather because of a poverty of speech or limited capacity for self-refection.  In this circumstance there are more structured interviewing strategies that may help to understand the client and enhance motivation for change.  The Decisional Balance Exercise and Personal Rulers Worksheet in Module 2 may be helpful for this purpose.

Transition to discussing treatment
Over the course of this session the therapist should keep a strong mental checklist of the client’s major self-motivating statements and be prepared to synthesize this change talk in a final transitional summary reflection.  The therapist will reach a point where further questions and reflection do not seem to generate any new or additional change talk.  At this natural ending point, the therapist should use the transitional summary as a means of shifting focus from the open MI portion of the session to discussing the goals and structure of the treatment.

Although smaller interim summary reflections are used throughout the beginning of this session to convey understanding and empathy, the use of the transitional summary allows the client to hear the collection of self-motivational statements synthesized together.  That is, first the client says it, then it is reflected back by the therapist, and the therapist reflects it again in a transitional summary.  This repetition of change talk is one of the essential processes that make MI effective (Miller and Rollnick, 2002).
	“I think I have a good idea about why you are here today and what your concerns 	are.  Let me see if I can summarize what I have learned about you.  Please let me 
	know if I have gotten something wrong or if there is anything you would like to 
	add to my understanding, OK?”

“You came to this first session not really sure what to expect and unsure about whether you really need to be in treatment.  The health survey you completed seemed to indicate that your drinking is at a risky level.  You recognize that your drinking is more than most people, but you don’t see much harm coming from it.  There are things you are worried about such as how drinking affects your weight, blood pressure, and sleep.  These are areas of your life that you would like to change but quitting drinking seems like a drastic move at this point.”

Following the transitional summary the therapist should pause to allow for clients to respond or reflect.  Sometimes a question following the feedback can facilitate client responses:
	
	“How does that sound to you?”
“Is there anything you would add that you think would help me to better understand you?”
“Does that sound about right?”

Discuss the structure and goals of the treatment

“We have talked some about the reasons you have come to work with me.  Now I would like to talk about what this treatment may have to offer to you, how often we will meet, and what we can focus on in here that may be helpful to you.”

“Today is the first of up to twelve sessions that we have to work together.  In this first session I am most interested in learning about what has brought you here and what you hope to get out of this treatment.  After today’s session, we can work together to decide what would make sense for us to focus our time on, and how long we should work together. How does this sound to you?”

Complete agency specific tasks
The goal of this initial session is to begin to understand the client and enhance motivation for change.  Agency-specific paperwork is necessary within any session and setting but may be more directive questioning and information gathering than an MI approach.  Placement of this essential task is between MI-consistent tasks in order to maintain an MI style.

Summarize session
The therapist should provide a closing summary of the session highlighting major accomplishments made during the session, reviewing any commitments the client has mad to try out new strategies, and recognizing the client’s efforts.

“ I would like to wrap-up for today and tell you about what is to come in out next session.  We have covered a lot of ground today and I appreciate the time and effort you have put in to this with me.  It is clear that you have some concerns about your health and how drinking may impact that in the long term.  You are not quite sure what to do about it.  You don’t see any immediate crises in your life because of drinking that would make you want to stop altoghether, but you are unsure of how much worse it might get if you don’t take some steps now.  Over the next few sessions working together, we can begin to talk about some of these questions you have about where to go from here, and I hope that you will be able to make some plans that make sense for you.”	

Preview next session
“In our next session, we can begin talking more about how you make a decision like this.  There are some aspects of any change that may be good, and some that may not be so good.  If we can talk about both the good and not so good things about changing, you may be better able to make the decision that you want.  How does this sound to you?”

Review home assignment
The recommended homework assignment for this session is to have the client begin thinking about the advantages and disadvantages of making a change.

“I have an exercise that might help you to get started thinking about our next session.  Would you be willing to work on something between now and then?”

“On this worksheet I have two lists.  On one side are the not so good things about making a change.  There are the things you might miss about using cocaine, or the things that would make giving it up difficult.  On the other side are the good things about making a change.  These are the things you look forward to if you can achieve your goal.  It may also be some of the negative things you can avoid by making a change.”

End session
“It was good to get started with you today.  I think we have gotten a good start and I look forward to talking more in our next meeting about your goals for treatment.  Do you have any other questions, concerns, or thoughts before we end today?”

References

Miller, W.R. (Ed.) (2004).  Combined Behavioral Intervention manual: A clinical research guide for therapists treating people with alcohol abuse and dependence.  COMBINE Monograph Series, (Vol.1). Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. DHHS No. 04-5288

Miller, W.R., & Rollnick, S. Motivational interviewing: Preparing people for change (2nd ed.) (2002).  New York: Guilford Press.

Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of self-change of smoking: toward and integrative model of change. J Consult Clin Psychol. 51, 390-395

MODULE 1
ENHANCING MOTIVATION
FOR CHANGE

APPENDIX A
ENHANCING MOTIVATION
FOR CHANGE
SESSION MATERIALS

DECISIONAL BALANCE WORKSHEET

Good things about changing

Not-so-good things about changing

Good