Relationship Enhancement Skills & Mining For Change Talk - Intermediate Training in Motivational Interviewing

8/15/13
Objec4ves
Discuss how MI methods can be adapted for use with special
Angela R. Bethea, Ph.D.

Licensed Psychologist
Bethea Consul9ng & Psychological Services, P.C.
Atlanta, Georgia

Department of Behavioral Health and
Developmental Disabili9es
and culturally diverse popula9ons.

U9lize 3 MI principles or interviewing skills to roll with sustain
talk and rela9onship discord.

U9lize 3 MI principles or interviewing skills to elicit and
strengthen change talk.

Prac9ce ra9ng transcripts to rate interven9onists MI delity.
and
Planning Commitment
ac9on plan.
Evoking
Focusing
Engaging
Elici9ng the clients

mo9va9ons for change.
Focus on a par9cular agenda.

Claries direc9on in conversa9on.
The process of establishing a mutually

trus9ng and respecRul helping rela9onship
(aspect of Bordins working alliance).
How do I iden4fy change and sustain

talk?

DARN
CATS
Preparatory Language
DARN: Desire
Miller, Moyers, Amhrein & Rollnick (2006)
A wan9ng, wishing or willing. They do not express
specic reasons, but express a general level of desire.

CT: I want, I wish, I (would) like, I am mo4vated to,
I (would) enjoy.
ST: I dont want to, etc.

Ex. I want to lose some weight. Change Talk

Ex. I dont want to exercise. Sustain Talk
8/15/13
DARN: Ability
Personal percep9ons of capability or possibility of
change. Generally express a level of ability or

inability.

CT: I can, I am able to, its possible for me, I could,
I would be able to.
ST: I cant

DARN: Reason
Species a par9cular ra9onale, basis, incen9ve,
jus9ca9on, or mo9va9on for making (or not making)

the target change. CT statements have an Ifthen
structure.

Ex. If I exercise more, then I might sleep be_er. Change Talk

Ex. Exercise just wont t into my schedule. Sustain Talk
Ex. I could quit smoking. Change Talk

Ex. I just cant quit smoking because I dont have the
willpower. Sustain Talk
DARN: Need
Mobilizing Language
CATS: Commitment
General importance, urgency, or requirement (for
Agreement, inten9on or obliga9on to future target
change or non-change). Usually, these statements do

not include specic reasons, but express general level
of need.

I need, I must, I have to, Ive got to, I cant keep on

like this, Something has to change

Ex. I have to stop gh9ng when I feel threatened.
Change Talk
Ex. I just need to accept that this is how I am. Sustain Talk
change.

CT: I promise, I guarantee, I am prepared to, I
swear I am going to do it, I believe I will, I intend
to**
ST: I dont intend to change, Im not going to

Ex. I am going to take my medica9on. Change Talk

Ex. I am just not going to take my medica9on anymore.
Sustain Talk
Mobilizing Language
CATS: Ac4on
Mobilizing Language
CATS: Taking Steps Toward Change
Current movement toward or away from change.

Almost there language. Commitment without
Describe a par9cular ac9on that the person has done
sta9ng it.

I am willing to, I am ready to, I am prepared to.

Ex. I am ready to stop smoking marijuana. Change Talk
in the recent past that is clearly linked to moving

toward or away from target change.

Ex. This week, I didnt snack aaer 8:00pm. Change Talk

Ex. I threw away the diet monitoring sheet. Sustain Talk

Ex. I am not willing to do what it takes to stop smoking
marijuana. Sustain Talk
8/15/13
How do I evoke change talk? 10 Ways

1. Evoca9ve ques9ons
2. Ask for elabora9on
3. Ask for examples
4. Looking backward
5. Looking forward
6. Query extremes
7. Use change rulers
8. Explore goals and values
9. Come alongside
10. OARS
Evoca4ve Ques4ons
Evoca4ve Ques4ons
Directly ask the individual for change talk.
Directly ask the individual for change talk.
Miller & Rollnick (2012); Rosengren (2009)
Why would you want to make this change? (Evokes Desire)

How might you go about it, in order to succeed?
(Evokes Ability)
What might be some reasons to quit if you were to do
so? (Evokes Reason)
How important is it for you to make this change, and
why? (0 10; Evokes Need)
So what, if anything, do you think youll do?
(Evokes Commitment)
What are you ready or willing to do? (Evokes Ac9on)

What have you already done? (Evokes Taking Steps)
Ask for Examples

Elabora4on
When change talk emerges, ask for specic examples.
Ask for details.

Tell me a recent 9me when you spent money on
what you need versus on alcohol.
Whats an example of when you used your anger
Tell me about a 9me when you decided to s9ck with

a decision despite others discouragement.
When was the last 9me you used your reality tes9ng
You said things might be be_er for you. Tell me
What does your anger look like when you feel
about how you might func9on be_er if you were to

take your medica9on regularly.
management skills?
skills?
threatened?
8/15/13
Looking Backward
Looking Forward
Asks the individual how things will appear if not change
Ask the individual to remember how things were before
happens or how things might look

a_er change.
How would you like things to be dierent?

If nothing changes, what do you see happening in 5 years? If

you decide to change what would it be like?
in making changes, what would
If you were 100% successful

be dierent?
How would you like your life
to be dierent one week from
now?

What might happen if you dont make any changes?
problems emerged. The helper can then guide the individual to

contrast those descrip4ons with how things are now.
When was a 9me when things were going well for you? How
did things change over 9me?
What are the dierences between you 10 (or 20 years ago)
and you now?
What did you envision for your life when you were young?
Before your drinking became a problem, how were things
be_er? Dierent?
Change Rulers
Query Extremes
Importance
Condence
Help the individual imagine the worst imagined outcomes if the
behavior con4nues, and the best benets if change occurs.

What are the best things that might happen if you do make
the change?
What do you hope for the most?
What would a perfect outcome look like?
What concerns you the most?
What is the worst thing that could happen?

On a scale from 0 to 10, where 0 is not ________, and
10 is extremely ________, where would you say you are?
0
10
Exploring Importance, Condence &

Readiness

Why are you at x and not x-2? (always start with the
higher number to evoke Importance)

How much do you want to make this change?
(Evokes Desire)
How were you able to make these changes in the past?
(Condence)

Exploring Importance, Condence &

Readiness
How might I help you go from a ___ to a [higher
number]? (Condence)
How condent are you that you could make this
change? (Evokes Ability)
What would be your rst step in making a change?
(Readiness)
8/15/13
Explore Values and Goals

Explore how the target behavior ts in with the values and
goals the client holds dearest:

What things do you regard as most important? How does
your drinking ts into this?

What sort of person [parent, daughter, son, wife, partner] do
you want to be?

Explore Values and Goals

Explore how the target behavior ts in with the values and
goals the client holds dearest:

What sorts of things would you like to accomplish in your
life?

Value Card Sort could be helpful to determine whether the
target behavior helps realize a goal/value or interferes with
the goal/value.
Come Alongside
Side with the status quo (sustain talk) side of ambivalence.

Perhaps drinking is so important to you that you wont give it
up, no ma_er what the cost.

**Landing on this side of ambivalence evokes the change talk side
of ambivalence.

Responding to Change Talk: OARS

Elabora9ng with

Open Ques9ons

Arming
Reec9ng
Summarizing
Asking for elabora9on or more

detail. Ex. In what ways will
you? Tell me about a 9me
Recognize or prize what the
person is saying about change
with a posi9ve comment.
Convey understanding with a
simple or complex reec9on.
Collect and give back bouquets
of change talk.
8/15/13
Sustain Talk
One side of ambivalence.
It cannot be recognized unless you know the change target(s)
or focus of treatment.
ST is not discordant, although the helpers response can
quickly make it so.
The more people verbalize and explore ST, the more they talk
themselves out of change.
CT statements should counterbalance ST by a 2:1 or 3:1 ra9o.
Reec4ve Responses to Sustain Talk:

Straight Reec4on

Client:

Helper:

Client:

I dont think that anger is really my

problem.
Your anger hasnt caused any dicul9es

for you.
Well, sure it has. Its ruined my rela9onship with

my mom.

Amplied Reec4on
Adds intensity in an overstatement to evoke the other side of
ambivalence: CT

Client:
I think things are just ne living with my mom.

Helper:
Theres really no room for improvement.

Client:
Well, things are perfect, but Im happy living

there, but my mom isnt, I guess.

Double-Sided Reec4on
Strategic Responses to Sustain Talk:

Emphasizing Autonomy

Helper:

Client:
I really dont want to take my medica9on.

Helper:
I hear you loud and clear, and its certainly your

choice whether you take your medica9on or not.

No one can make you do it.

Other Examples:
Its really up to you; I wonder what youll decide to do!;
What you choose to do is your business; Even if I wanted to
decide for you, I cant.
Its so easy to keep things as they are. At the

same 9me, youre trying to gure out how you
can become more ac9ve in gexng your
independence back, living on your own and
gexng back to work.
8/15/13

Reframing

Agreeing with a Twist

Client:
Helper:

Client:
Helper:

Client:

Helper:
A reframe.

Client:

Helper:

My girlfriend is always nagging me about this.

She must really care about you.
Everybody I know smokes as much weed as I do.
You really smoke with the best of them!
Ive been through so much lately, Im not sure I
can take this on too.
Youre quite a survivor.

Running Head Start
For ambivalent clients: Get a running head start toward arguments for
change by listening to the cons. Hear out the mo9va9ons for status
quo rst, especially when CT is scarce.

Client:
I need to get a job.
Helper:
Yes, but what have you really enjoyed about

being unemployed?

**Follow-up with asking about the downside of the status quo and the
advantages of change.

**If you have a good amount of CT, theres no need to go shing
for ST.

I can really hold my liquor and drink folks under

the table. It just doesnt aect me the way it
does other people. Im s9ll standing while others
are passed out.
You dont show or feel the eects of alcohol the
way other people do. Thats how you operate.
I can see how that would be a concern.

Come Alongside
Agreement without a twist

Client:
Ive tried this AA thing a million 9mes and it

doesnt work for me. How can other people with

drinking problems tell me what to do? Plus, I just

get too nervous. I get to scared to open up, then

I just clam up. Its not for me.

Helper:
It really may be too dicult for you. AA is not the

best t for everyone, even though its eec9ve. Being

a part of a group means making your contribu9on and

it might not be worth the discomfort. Perhaps its

be_er to stay as-is.
Discord: What are the signs of a re in

your working alliance?
Smoke Alarms
Defending (Feel threatened or a_acked):
Blaming: Its not my fault.
Minimizing: Its not that bad.
Jus9fying: What Im doing makes sense.

Squaring o (The helper is perceived as an adversary. An
invita9on to a power struggle, to argueClient holds the
power):
You dont care about me.
You have no idea what its like for me.
8/15/13


Smoke Alarms
Interrup9ng: This may communicate
You dont understand.
Youre not hearing me.
Youre talking to much, listen to me.
I dont agree.
Smoke Alarms
Disengagement
Seems ina_en9ve, distracted or ignores you.
May change the subject and go o on a tangent.
Eyes glaze over and glance at the clock.
Discord and the 4 Processes: Engaging
Discord and the 4 Processes: Focusing
Some people walk through the door angry and defensive.

In response to mul9ple closed ques9ons.
May surface when the helper falls into Labeling or Blaming
Traps.
Disagreement about what to discuss and the targets for
change.
When the helper falls into the Premature Focus Trappushing
too soon for a change target that the client does not yet share.
Discord and the 4 Processes: Evoking
Discord and the 4 Processes: Planning
Sustain talk emerges, even for clients with are well-engaged
Its temping for helpers to think, Ok, I can take it from here.
and who have found a treatment focus. This is a normal part

of ambivalence.
If the helper pushes the conversa9on in a direc9on that the
client is not ready for OR moves past evoking to planning,
discord can emerge.
Helper:

Now let me tell you what to do. Thats the Righ9ng Reex
Planning needs to be a collabora9ve process. A helpers
Righ9ng Reex and a clients ambivalence creates wrestling

(not dancing) in the rela9onship.
Youve told me several reasons why taking your

medica9on could be a good idea. So, what are
you going to do about it?
8/15/13
Responding to Discord: Reec4ons

Client:
Who are you? And, how old are you? You cant

understand me.

Helper:
SR: Youre wondering if I can really be able to help you.
CR (Amplied): It seems to you theres no chance at all I could
help you.
CR (Double-Sided): Youre looking for some help and youre not
sure Im the best t for you.
Responding to Discord:
Emphasizing Autonomy

Client:

Helper:

Apologizing
When youve stepped on someones toes, its polite to say,
Sorry.

This costs you nothing and immediately acknowledges that this
is a collabora9ve and respecRul rela9onship.
Im not going to take my meds (Sustain Talk) and

you cant make me (Discord).
Thats right. I cant make any choice for you even if
I wanted to!
Arming
Can help to diminish defensiveness.

Client:

Helper:

I can do this on my own without your help!

Once you make up your mind about something you
can get it done.
Shi_ing Focus
Shia focus away from the hot topic or sore sport rather than
con9nue to exacerbate it.

Client:
Are you saying that the reason why my boyfriend

sent me to the hospital is my fault?

Helper:
Not at all. Im not interested in placing blame or

name-calling. What ma_ers to me is how you

would like your rela9onship to be be_er and how

you might get there.
rather than take responsibility for making individuals

change, support them in making and strengthening
their own arguments and plans for change!
8/15/13

Licensed Psychologist
Bethea Consul9ng & Psychological Services, P.C.
6 Concourse Parkway, NE
Suite 1650
Atlanta, GA 30328

E: angela.bethea@gmail.com
O: (404) 654-3614
W: www.betheacps.com
Introduc4on to MI Workshop
(2-3 days)

Intermediate/Advanced MI Training
(2-3 days)

Ongoing MI Consulta4on and Supervision
(Open-ended)

References
Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S. W., Moring, J., OBrien, R., Schoeld, N., & McGovern, J.
(2001). Randomized controlled trial of mo9va9onal interviewing, cogni9ve behavior therapy, and family
interven9on for pa9ents with comorbid schizophrenia and substance use disorders. American Journal of
Psychiatry, 158, 1706-1713.
Bem, D. J. (1972). Self-percepGon theory. Advances in Experimental Social Psychology.
Jones, S. H., Barrowclough, C., Allo_, R., Day, C., Earnshaw, P., & Wilson, I. (2011). Integrated mo9va9onal
interviewing and cogni9ve-behavioural therapy for bipolar disorder and comorbid substance use. Clinical
Psychology & Psychotherapy, 18, 426-437.
Mar9no, S. (2007). Contempla9ng the use of mo9va9onal interviewing with pa9ents who have
schizophreniaand substance use disorders. Clinical Psychology: Science and Prac9ce, 14, 58-63.
McCracken, S. G., & Corrigan, P. W. (2008). Mo9va9onal interviewing for medica9on adherence in
individuals with schizophrenia. In H. Arkowitz, H.A. Westra, W.R. Miller, S. Rollnick (Eds.), MoGvaGonal
interviewing in the treatment of psychological problems (pp. 249-276). New York: The Guilford Press.
Mar9no, S., & T. B. Moyers (2008). Mo9va9onal interviewing with dually diagnosed pa9ents. In H.
Arkowitz, H.A. Westra, W.R. Miller, S. Rollnick (Eds.), MoGvaGonal interviewing in the treatment of
psychological problems (pp. 277-303). New York: The Guilford Press.
References
Miller, W. R., & Baca, L. M. (1983). Two-year follow-up of bibliotherapy and therapist-directed controlled
drinking training for problem drinkers. Behavior Therapy, 14, 441-448.
Miller, W. R., Beneeld, R. G., & Tonigan, J. S. (1993). Enhancing mo9va9on for change in problem drinking:
A controlled comparison of two therapist styles. Journal of ConsulGng and Clinical Psychology, 61, 455-461.
Miller, W. R., Moyers, T. B., Amhrein, P., & Rollnick, S. (2006). A consensus statement on dening change
talk. MINT BulleGn, 13(2), 6-7.
Miller, W. R., & Rollnick, S. MoGvaGonal interviewing: Helping people change (3rd ed.). New York: The
Guildford Press, 2012.
Miller, W.R., & Rose, G.S. (2009). Toward a theory of mo9va9onal interviewing. The American Psychologist,
64, 527-537.
Moyers, T. B., Mar9n, T. (2006). Therapist inuence on client language during mo9va9onal interviewing
sessions. Journal of Substance Abuse Treatment, 30, 245-251.
Moyers, T. B., Miller, W. R., & Hendrickson, S. M. (2005). How does mo9va9onal interviewing work?:
Therapist interpersonal skill predicts client involvement within mo9va9onal interviewing sessions. Journal
of ConsulGng and Clinical Psychology, 73, 590-598.
Rollnick, S., Miller, W. R., & Butler, C. C. (2008). MoGvaGonal interviewing in health care: Helping paGents
change behavior. New York: The Guilford Press.
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8/15/13

Angela R. Bethea, Ph.D.

and culturally diverse popula9ons.

Elici9ng the clients

Focus on a par9cular agenda.

The process of establishing a mutually

How do I iden4fy change and sustain

A wan9ng, wishing or willing. They do not express

specic reasons, but express a general level of desire.

Angela R. Bethea, Ph.D.

Personal percep9ons of capability or possibility of

change. Generally express a level of ability or

Species a par9cular ra9onale, basis, incen9ve,

jus9ca9on, or mo9va9on for making (or not making)

Ex. I could quit smoking. Change Talk

Angela R. Bethea, Ph.D.

General importance, urgency, or requirement (for

Agreement, inten9on or obliga9on to future target

Miller, Moyers, Amhrein & Rollnick (2006)

change or non-change). Usually, these statements do

I need, I must, I have to, Ive got to, I cant keep on

Miller, Moyers, Amhrein & Rollnick (2006)

Current movement toward or away from change.

Describe a par9cular ac9on that the person has done

Miller, Moyers, Amhrein & Rollnick (2006)

Miller, Moyers, Amhrein & Rollnick (2006)

in the recent past that is clearly linked to moving

Angela R. Bethea, Ph.D.

How do I evoke change talk? 10 Ways

Angela R. Bethea, Ph.D.

Directly ask the individual for change talk.

Directly ask the individual for change talk.

Miller & Rollnick (2012); Rosengren (2009)

Why would you want to make this change? (Evokes Desire)

Miller & Rollnick (2012); Rosengren (2009)

How important is it for you to make this change, and

why? (0 10; Evokes Need)

So what, if anything, do you think youll do?

What are you ready or willing to do? (Evokes Ac9on)

Angela R. Bethea, Ph.D.

Angela R. Bethea, Ph.D.

Ask for Examples

Miller & Rollnick (2012); Rosengren (2009)

Miller & Rollnick (2012); Rosengren (2009)

When change talk emerges, ask for specic examples.

Ask for details.

Whats an example of when you used your anger

Tell me about a 9me when you decided to s9ck with

You said things might be be_er for you. Tell me

What does your anger look like when you feel

about how you might func9on be_er if you were to

Angela R. Bethea, Ph.D.

Miller & Rollnick (2012); Rosengren (2009)

Miller & Rollnick (2012); Rosengren (2009)

Asks the individual how things will appear if not change

Ask the individual to remember how things were before

happens or how things might look

problems emerged. The helper can then guide the individual to

Angela R. Bethea, Ph.D.

Angela R. Bethea, Ph.D.

Miller & Rollnick (2012); Rosengren (2009)

Help the individual imagine the worst imagined outcomes if the

behavior con4nues, and the best benets if change occurs.