Motivational Interviewing in Clinical Mental Health Counseling 2022015438, 2022015439, 9781138568266, 9781138568273, 9781351244596

Table of contents :
Cover
Half Title
Title
Copyright
Contents
List of Abbreviations
List of Figures and Tables
Preface
Acknowledgments
Part I Foundations of Motivational Interviewing
1 Introduction to Motivational Interviewing: Philosophy and Spirit
Introduction
What Is Motivational Interviewing?
The Spirit of Motivational Interviewing: The Recipe of Good Practice
Philosophy, Principles, and Clinical Stance
Clinical Mental Health Counseling and Motivational Interviewing
Summary
References
2 Skills and Technical Aspects of Motivational Interviewing
Introduction
Summary
References
3 Motivational Interviewing, Ambivalence, and Change Talk
Introduction
Case Study
Summary
References
4 Motivational Interviewing in Action: The Four Processes
Introduction
What Motivational Interviewing Looks Like in Practice
Case Study
Summary
References
Part II Applications of Motivational Interviewing in Clinical Mental Health Settings
5 Common Presenting Problems in Clinical Mental Health Settings and Motivational Interviewing
Introduction
Using Motivational Interviewing in Inpatient Mental Health Care Settings
Using Motivational Interviewing in Outpatient Mental Health Care Settings
Using Motivational Interviewing with Common Mental Health Problems
Case Study
Summary
References
6 Motivational Interviewing and Group Counseling
Introduction
Overview of Group Counseling Process
Incorporating Motivational Interviewing into Group Counseling Practice
Empirical Support
Contraindications
Case Study
Summary
References
7 Client Conceptualization: Using Motivational Interviewing Within the Clinical Evaluation Process
Introduction
Clinical Evaluation
Motivational Interviewing and the Evaluation Process
Assessment Feedback and Motivational Interviewing
Assessing Stages of Change and Motivation
Summary
References
8 Clinical Supervision from a Motivational Interviewing Perspective
Introduction
Case Study
Summary
References
9 Multicultural Counseling and Motivational Interviewing in the Clinical Mental Health Setting
Introduction
The Diversity of Counseling Clientele
Multicultural Counseling: The Fourth Force in Professional Counseling
Motivational Interviewing as a Culturally Sensitive Approach
Summary
References
Part III Training and Professional Development in Motivational Interviewing
10 Training and Professional Development in Motivational Interviewing
Introduction
Summary
References
Index

Citation preview

Motivational Interviewing in Clinical Mental Health Counseling

Motivational Interviewing in Clinical Mental Health Counseling is a cutting-edge guide to empowering counselors with the philosophical and actionable elements of motivational interviewing. This textbook, appropriate for primary or supplementary use in counseling coursework, is a practitioner and student-friendly text appropriate for readers across all levels of familiarity with motivational interviewing. Chapters integrate and present the newest conceptual and empirical literature, and the relevant, up-to-date content in each chapter is accompanied by a detailed case study and specific training exercises that will enhance counselors’ proficiency in core skills. Motivational Interviewing in Clinical Mental Health Counseling introduces new learners to the skills and philosophy of motivational interviewing, enhances the skills of veterans familiar to the framework, and is the perfect companion for students of motivational interviewing across a variety of mental health counseling courses. Todd F. Lewis, PhD, is a professor of counseling and counselor education at North Dakota State University. He is a member of the Motivational Interviewing Network of Trainers (MINT). Edward Wahesh, PhD, is an associate professor in the Department of Education and Counseling at Villanova University. He is a member of the Motivational Interviewing Network of Trainers (MINT).

Motivational Interviewing in Clinical Mental Health Counseling

Todd F. Lewis and Edward Wahesh

Cover image: From Getty First published 2022 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 Todd F. Lewis and Edward Wahesh The right of Todd F. Lewis and Edward Wahesh to be identified as authors of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Lewis, Todd F., author. | Wahesh, Edward, author. Title: Motivational interviewing in clinical mental health counseling / Todd F. Lewis, Edward Wahesh. Description: New York, NY : Routledge, 2022. | Includes bibliographical references and index. Identifiers: LCCN 2022015438 (print) | LCCN 2022015439 (ebook) | ISBN 9781138568266 (hardback) | ISBN 9781138568273 (paperback) | ISBN 9781351244596 (ebook) Subjects: LCSH: Motivational interviewing. | Interviewing in mental health. | Mental health counseling. Classification: LCC BF637.I5 L45 2022 (print) | LCC BF637.I5 (ebook) | DDC 158.3/9—dc23/eng/20220524 LC record available at https://lccn.loc.gov/2022015438 LC ebook record available at https://lccn.loc.gov/2022015439 ISBN: 978-1-138-56826-6 (hbk) ISBN: 978-1-138-56827-3 (pbk) ISBN: 978-1-351-24459-6 (ebk) DOI: 10.4324/9781351244596 Typeset in Sabon by Apex CoVantage, LLC

Contents

List of Abbreviations List of Figures and Tables Preface Acknowledgments

viii ix x xiii

PART I

Foundations of Motivational Interviewing 1 Introduction to Motivational Interviewing: Philosophy and Spirit

1

3

Introduction 3 What Is Motivational Interviewing? 3 The Spirit of Motivational Interviewing: The Recipe of Good Practice 6 Philosophy, Principles, and Clinical Stance 10 Clinical Mental Health Counseling and Motivational Interviewing 13 Summary 15 References 16 2 Skills and Technical Aspects of Motivational Interviewing

18

Introduction 18 Summary 34 References 35 3 Motivational Interviewing, Ambivalence, and Change Talk Introduction 36 Case Study 49 Summary 52 References 52

36

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Contents

4 Motivational Interviewing in Action: The Four Processes

56

Introduction 56 What Motivational Interviewing Looks Like in Practice 56 Case Study 66 Summary 72 References 72 PART II

Applications of Motivational Interviewing in Clinical Mental Health Settings 5 Common Presenting Problems in Clinical Mental Health Settings and Motivational Interviewing

75

77

Introduction 77 Using Motivational Interviewing in Inpatient Mental Health Care Settings 78 Using Motivational Interviewing in Outpatient Mental Health Care Settings 80 Using Motivational Interviewing with Common Mental Health Problems 80 Case Study 89 Summary 91 References 92 6 Motivational Interviewing and Group Counseling

95

Introduction 95 Overview of Group Counseling Process 96 Incorporating Motivational Interviewing into Group Counseling Practice 102 Empirical Support 107 Contraindications 109 Case Study 110 Summary 112 References 112 7 Client Conceptualization: Using Motivational Interviewing Within the Clinical Evaluation Process Introduction 115 Clinical Evaluation 115

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Contents

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Motivational Interviewing and the Evaluation Process 120 Assessment Feedback and Motivational Interviewing 120 Assessing Stages of Change and Motivation 124 Summary 128 References 130 8 Clinical Supervision from a Motivational Interviewing Perspective

132

Introduction 132 Case Study 148 Summary 151 References 152 9 Multicultural Counseling and Motivational Interviewing in the Clinical Mental Health Setting

154

Introduction 154 The Diversity of Counseling Clientele 154 Multicultural Counseling: The Fourth Force in Professional Counseling 155 Motivational Interviewing as a Culturally Sensitive Approach 157 Summary 162 References 164 PART III

Training and Professional Development in Motivational Interviewing

167

10 Training and Professional Development in Motivational Interviewing

169

Introduction 169 Summary 179 References 180 Index

183

Abbreviations

ASA CATs CMH CMHC DARN DSM EARS EPE FRAMES MI OARS PACE

Ask share ask Commitment, activation, taking steps Clinical mental health Clinical mental health counseling Desire, ability, reasons, need Diagnostic and statistical manual Elaborate, affirm, reflect, summarize Elicit provide elicit Feedback, responsibility, advice, menu, empathy, self-efficacy Motivational interviewing Open questions, affirmations, reflections, summary Partnership, acceptance, compassion, evocation

Figures and Tables

Figures 7.1 The Clinical Evaluation and Its Components

116

Tables 2.1 Examples of Affirmations Contrasted with Praise 3.1 Examples of Change Talk from Evoking a Client’s Motivation to Engage in Treatment 4.1 Questions to Guide the Planning Process 7.1 Assessing Importance and Confidence to Understand Motivation 9.1 Multicultural Considerations Throughout the Counseling Process

21 42 66 126 156

Preface

Motivational Interviewing in Clinical Mental Health Counseling (MICMHC) is a guide to empowering professional clinical mental health counselors with the philosophical and actionable elements of motivational interviewing (MI). This textbook, appropriate for primary or supplementary use in counseling coursework, is a practitioner and student-friendly text appropriate for readers across all levels of familiarity with MI. MICMHC is a unique addition to one’s MI library in that it (a) integrates and presents conceptual and empirical literature relevant to clinical mental health counseling and (b) emphasizes learner synthesis of each chapter’s contents by detailed case studies and training activities/resources. MICMHC introduces new learners to the skills and philosophy of MI, enhances the skills of veterans familiar to the framework, and provides commentary on how MI can be incorporated within the responsibilities of clinical mental health agencies. There are many texts on the topic of MI, including its application in social work, correctional settings, schools, personal growth, and exercise and nutrition. Other MI texts focus on specific issues, populations, and procedures, including using MI in groups, as an approach to ease anxiety-related issues, and with children and adolescents. A logical question, then, is why another book on MI, and how is this different from other texts? MI is a highly effective approach to behavior change that has yet to be fully integrated into the field of professional counseling. The past 25 years of research and practice have led to the integration of MI into psychiatry, medicine, nursing, social work, and health education; however, there is no comprehensive resource for one of the largest fields in mental health practice, professional counseling. The Bureau of Labor Statistics suggests that upward to 165,100 clinical mental health counselors will be employed in the United States in 2022. As such, we sought to write a book for clinical mental health counselors and counseling students that can help guide them in the implementation of MI within their respective clinical settings. Given that clinical mental health counselors are beginning to implement MI and identify themselves as a distinct population

Preface

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that uses MI, it is appropriate that a book is written to guide them in their journey toward competence and application. Another motivation for writing this book was the observation that MI is given such limited attention, if any at all, within clinical mental health counseling and counseling theory texts. Usually, two to three pages or less are dedicated to the approach, which of course is not nearly enough to convey the foundational elements and nuances of MI. As we have heard many times in our trainings, MI is simple to understand but not easy to apply. We hope that in this text we can bridge this gap by strengthening the reader’s understanding and application of MI. In this three-part book, we build on Miller and Rollnick’s (2013) third edition of their classic text, which provides a critical foundation for mental health counselors to effectively use MI. Part I addresses the philosophy and “nuts and bolts” of MI to prepare the reader for application in clinical mental health (CMH) settings. In Part II, we apply MI to evaluation and assessment, common clinical problems, clinical supervision, and group counseling. A chapter on multicultural counseling and MI addresses using the approach within increasingly diverse clientele in clinical mental health agencies. Part III concludes the text with a focus on how clinical mental health counselors can gain further training and competence in the practice of MI. Our hope is that this book will appeal to mental health counselors, counselor educators, and counselors-in-training who want a fresh overview of MI and strategies for its application within CMH settings. MICMHC can be used as a stand-alone guide to MI, making it an important addition to student, instructor, and practitioner libraries, or as a companion text for courses in clinical mental health counseling, practicum, internship, and helping skills. Though the book may be applied as a complement to Miller and Rollnick’s (2013) text, both veteran and new mental health counselors with little background in MI will find success using MICMHC as a primary text as well.

A Word About Language We would like to say a few words about language usage in the text. We come from the perspective that language does matter! For example, there are many words that can be used in place of counselor—clinician, mental health counselor, therapist, helper, listener, clinical mental health counselor, CMH counselor, and so forth. This is a book primarily targeted to clinical mental health counselors, and so our most utilized terms are counselor, clinical mental health counselor, and CMH counselor. However, we also recognize that other mental health professionals work in clinical mental health agencies. As such, you will occasionally see words such as clinician and practitioner. Whatever term we use, assume that our intention is to refer to clinical mental health counseling students and

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Preface

those who are licensed (or licensed eligible) to provide clinical mental health services. Another common language issue includes using “his or her” when discussing a single client example. We have removed this rather awkward reference and simply choose “they” as a generic third-person singular pronoun. However, if the gender of the client and/or counselor in a case vignette is known, we use “his” or “her” in these instances. We have tried to be as inclusive as possible by providing a diverse array client examples. At the end of most chapters, we provide case studies to demonstrate the chapter concepts. The case studies are composite narratives of clients and supervisees who we have served over the years. All identifying information has been removed. You will notice that MI uses a lot of abbreviations. We attempt to always spell out the acronym before using it subsequently in the text; however, we may not have succeeded with every instance. Please refer to the list of abbreviations in this front matter if you are unsure on the meaning of an acronym.

Activities and Resources Another unique feature of the book is the activities and resources section at the end of most chapters. A quick google search will no doubt provide a bevy of resources for anyone who wants to know more about MI. Although we do include some websites as resources, we also provide exercises, videos, books, and activities based on our training and teaching in MI. We believe these resources and activities can be invaluable in learning MI. As with most clinical approaches, students and practitioners need more than a quick overview; they also need to see it in action and then practice what they see. This “tell-show-do” is a common approach to teaching MI skills. In this book, we offer the “tell” and “show” parts, but it is up to the reader to take this and compete the “do.” Chapter 10 of the text offers a multitude of ways this can be done.

Reference Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford.

Acknowledgments

Over the years we have studied and trained in MI, written many articles and chapters, and presented at many conferences and webinars. We are humbled by the students, practitioners, and teachers who have attended our workshops and trainings. They have inspired us to do our best to teach the approach so that they can confidently practice MI. As with all projects like this, we have stood on the shoulders of giants in the MI field. From professional trainings with MI leaders, to working with and consulting members of the Motivational Interviewing Network of Trainers (MINT), our knowledge, proficiency, and skills in MI are the amalgamation of excellent instruction, feedback, and hard work. We are grateful to those who have taught us the approach, and we are committed to carrying on the torch.

Todd F. Lewis This project has had a tumultuous run, with several starts, stops, and iterations since we stated our vision and wrote our outline in 2017. I am grateful to our publisher at Routledge, Anna Moore, who believed in the project and encouraged us along. Due to the COVID pandemic, we had to ask for yet another extension and Anna was gracious and supportive in that effort. I also would like to thank my personal MI teachers, Dr. Cynthia Osborn and Cathy Cole, whose proficiency in MI is stellar. Your talents and professionalism are something I will always remember and try to emulate every day. Finally, I would like to thank my beautiful wife and children, Denise, Evie, and Alex. You have remained inquisitive, supportive, and patient during this process, especially when I practice my reflective listening during our conversations unbeknownst to you. I love you all to the moon and back!

Edward Wahesh This book represents what I have learned practicing, teaching, and coaching MI over the past 15 years. I am grateful for the guidance of the many

xiv Acknowledgments supervisors, professors, and colleagues who have helped me understand and learn to embody the spirit of MI. I am particularly indebted to the first author, Todd F. Lewis, who has been a mentor to me since my days as a doctoral student, for his guidance and support during this project. I would also like to thank the many clients, students, and supervisees who I have had the privilege of working with through the years. They influenced my practice of MI and served as an important source of motivation that kept me committed to finishing this project. And, finally, I owe the greatest debt to my wife Rachel and son Luke who tolerated my occasional lack of presence and distracted mind during the writing project.

Part I

Foundations of Motivational Interviewing In Chapters 1–4, we introduce the reader to the philosophy and skills of motivational interviewing (MI), with specific foci on the role of ambivalence in making change, change talk, and seeing MI in action through the four processes. Case examples or brief demonstrations reflect common situations in which clinical mental health counselors can implement and utilize MI. The chapters provide a solid grounding in MI to prepare the reader for its application in CMH settings (in Part II of the book). Each chapter concludes with activities and resources designed to assist mental health counselors in their application of MI.

DOI: 10.4324/9781351244596-1

1

Introduction to Motivational Interviewing Philosophy and Spirit

Introduction Motivational interviewing (MI) has matured into an evidence-based method of communication and counseling designed to help people explore their ambivalence about change. However, why would people be ambivalent and hesitant to change behavior in the first place, even if that behavior has clear negative consequences? Indeed, I (TFL) pondered this exact question in doctoral school, along with the fact that many of our (CMH) clients are reluctant to be in counseling, are coerced to attend, or are simply lacking in the motivation to follow through on clinical directives. At that time, I was searching for an approach to help navigate these difficult clinical scenarios and came across MI as a potentially effective approach. We say potentially effective approach because we do not believe that MI is a panacea or that it works every time with every client (unfortunately, the approach has been somewhat sold in this fashion, to the frustration of many experts in MI). MI is deceptively simple to understand, but not easy to implement. There are philosophical elements and technical aspects. However, when used appropriately, MI has potential to not only help the most resistant clients consider the possibility of change but also impact the culture of mental health counseling in a positive and constructive way. In this book, we explore MI within the multiple components of the CMH setting. In this chapter, we provide a definition of MI and review several important concepts such as MI spirit, principles, and philosophy. Emphasis will be placed less on technique and more on the underlying foundation. Our purpose is to provide the reader with a solid grounding in the clinical “stance” mental health counselors take when implementing MI. We conclude with an introduction to the importance and application of MI into the broader clinical mental health counseling (CMHC) scene, which comprises Part II of the book.

What Is Motivational Interviewing? MI is a method of communication and counseling designed to increase intrinsic motivation to change, lower resistance (or, in more recent MI DOI: 10.4324/9781351244596-2

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Foundations of Motivational Interviewing

literature, discord; Miller & Rollnick, 2013), and resolve ambivalence. MI also is designed to illuminate the client’s own language about change, explore this language, and encourage an examination about what this language means related to making substantive life changes. Language about change is called change talk and includes affirmative client statements recognizing a problem and/or that something needs to change to address the problem. For example, a client might say, “I realize my drinking is not helping my marriage.” This statement suggests that the client is aware of negative consequences related to drinking and may be contemplating change or is ready to consider talking about change in counseling. MI clinicians listen intently for change talk, illuminate it, explore it, reflect it, and encourage more of it to help move clients toward positive changes in their lives. Change talk has become a central feature of the MI method and will be given additional focus in Chapter 3. MI is considered a style of counseling rather than a theory (Miller & Rose, 2009), although it draws from already established humanistic and motivational psychological theories. In addition, MI was a response to overly confrontational approaches in substance addiction care. These approaches consisted of harsh confrontation, the need to break down denial, and propagated an “I know what is best for you” mentality. Unfortunately, these confrontational approaches were met with considerable client resistance, precluding client change, growth, and positive clinical outcomes. William R. Miller, the co-founder of MI, observed that clients often responded to these methods with palpable resistance, either by overtly rejecting the counselor’s suggestions or by sabotaging their own care. In other words, confrontational approaches, whereas well intentioned, produced the exact opposite of the desired effect in counseling: Clients left sessions angry, unmotivated, resistant, and still using substances! Over the years, MI has matured into an evidence-based approach for helping people change problematic behaviors. Although MI was born out of the addictions field, the list of applications continues to grow. Beyond addictions, MI has been used to help clients struggling with diabetes management (Steinberg & Miller, 2015), depression (Keeley et al., 2016), anxiety (Marker & Norton, 2018), psychosis (Rubenstein, 2016), and exercise and diet management (Edwards et al., 2015). MI also has found its way into medical health care settings, where the focus has been on training physicians in brief MI methods (Rollnick et al., 2008). MI is well established in the treatment of CMH problems (Arkowitz et al., 2015); however, there has been limited discussion related to MI’s application within the many facets of CMHC. The definition of MI has gone through several iterations over the years. In their seminal book on the topic, Miller and Rollnick (2013) stipulated three separate definitions of MI, depending on the audience. However, we will use their third, and most complete, definition to help us answer the question, “what is motivational interviewing?”

Introduction to Motivational Interviewing

5

Motivational Interviewing is a collaborative, goal-oriented style of communication with particular attention to language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. (Italics added, p. 29) This definition clearly outlines the priorities when using MI: Focus on collaboration, pay attention to change language, and elicit from clients their own motivations, attitudes, and feelings in an atmosphere of acceptance and empathy. Goals of Motivational Interviewing To understand MI, it is helpful to grasp what clinicians hope to accomplish when using this approach to helping. We will outline four overarching MI goals here, but keep in mind that within these goals may be clinical subgoals, and we admit that other MI experts may identify additional goals beyond the four we outline here. However, it is our belief that most, if not all, MI strategies and techniques are in the service of one of these four overarching goals. The first goal is to help clients increase their intrinsic motivation to change. Intrinsic motivation is a type of motivation that emanates from within the individual and includes behavior that is engaged in for its inherent satisfaction (Rockafellow & Saules, 2006). Motivation from within (as opposed to external) can lead to behaviors that have greater meaning (Rath, 2015) and, as such, may be less fleeting. Intrinsic motivation is akin to an inner resolve to make changes for the better; clients have a firm investment in improving their lives, the internal satisfaction that positive changes bring, and enhanced purpose. Intrinsic motivation can be contrasted with extrinsic motivation or motivation that comes from outside the person. Extrinsic motivation depends on external rewards to influence behavior and, when the rewards are no longer offered or available, motivation tends to wane (Kohn, 2018). This is not to say that extrinsic motivation is “bad” and never explored within MI. Indeed, researchers have recently revisited the concepts of intrinsic and extrinsic motivation and suggested that they don’t necessarily have to be in conflict with each other and can, depending on circumstances, be mutually facilitative (Locke & Schattke, 2018); regardless, the balance of focus in MI is more on clients making their own arguments for change rather than hearing arguments from some outside source. From the MI perspective, this type of motivation is generally observed as leading to more meaningful and last change. The second goal of MI is to lower the level of resistance within the counseling session. Resistant behaviors can come in all shapes and sizes, but the overall experience is that the counselor and client are not on the

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same page. A client (or counselor!) may argue, defend, ignore, or interrupt during the session, which are telltale signs of resistance. In general, too much resistance within a counseling session can thwart clinical progress. As such, a central goal of MI is to lower its presence so that space opens for new possibilities. We will have much more to say about resistance and the now preferred term, discord, as well as strategies to address these issues, in Chapter 2. The third goal of MI is to resolve ambivalence. When clients are considering the possibility of change, they often struggle with two competing viewpoints. For example, a client who wishes to stop drinking may see several reasons why that may be a good idea, and see reasons why stopping would be difficult and/or undesirable. According to Miller and Rollnick (2013), ambivalence is a primary reason why clients remain stuck and are unable to change. The competing forces (arguments for change and arguments against change) pull back and forth like a psychological tug-of-war. In MI, resolving ambivalence is the key to helping clients find the energy and motivation to change problematic behavior. Many strategies within MI and shared throughout this book were designed to help clients resolve ambivalence. The explosion of research over the past 20 years has shed new light on the importance of client change language (called change talk) when assessing the commitment to making positive life changes. The fourth goal of MI is to emphasize and illuminate client change talk. The stronger the change language, the higher the probability of change. All change talk is not created equal, however. For example, clients may share a desire to change (“I would like to cut down on my drinking”) but may not be ready to fully commit. On the other hand, a client may convey a strong commitment to change (“I will cut down on my drinking”) and thus carry through with this commitment. In other words, change talk can come in varying degrees of seriousness and intensity. Change talk and ways to elicit this type of language will be explored in Chapter 3. We now turn to a critical foundation of the MI approach: MI spirit.

The Spirit of Motivational Interviewing: The Recipe of Good Practice There are four components to MI spirit: collaboration, evocation, acceptance, and compassion (Miller & Rollnick, 2013). Rollnick (2010) likened MI spirit to the spices in a good curry. As with any recipe, when all the spices or ingredients are added in their proper amounts, a beautiful dish comes together with all flavors combining to create a great taste. Similarly, when all the components of MI spirit are working together, the counselor provides the foundation for good counseling practice and can build a meaningful session for their client. Imagine the taste of a culinary dish without a key missing ingredient; something would be off as the dish

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would not taste quite right. Similarly, if an element of MI spirit is missing, the approach also doesn’t quite “taste” right. For example, without evoking, the counselor may take over the session, making suggestions and offering advice without first asking the client about his or her thoughts, feelings, attitudes, and hopes. From an MI perspective, such a session would feel lop-sided, and the chances of higher discord increases. Let’s review each of the MI spirit components below. At its core, MI is a collaborative approach to helping, a partnership where counselor and client explore the possibilities for change. The client is thought to offer a valuable perspective to the counseling process, one that should be honored and explored. Collaboration allows the MI practitioner to relax the need to be the expert and instead join with the client to figure out a way forward. This does not mean that the counselor forgoes his or her expertise. Mental health counselors certainly have information and advice to share with clients that can open new avenues of exploration. However, how the information and advice are provided make all the difference in MI. Briefly, MI practitioners focus on asking permission before offering information/advice, providing information in small chunks, and checking in with clients to see what they make of the information just offered. Counselors who emphasize too much of the expert role, without enough collaboration, can inadvertently increase discord. More about how providing information and advice fits within the MI method will be provided in Chapter 4. The second component of MI spirit is evocation. Evoking client views, perceptions, attitudes, hopes, and fears can be a powerful process that promotes feeling valued and having an important role in their own counseling. In my (TFL) clinical experience, many clients come to counseling expecting to be told what to do because that is how the outside world has treated them. They have been told by loved ones or “experts” to exercise more, eat right, stop drinking, be less angry, be more relaxed, stop obsessive thinking, control their behavior, be a better “fill in the blank” (husband, wife, partner, sibling, etc.). Although this advice generally comes from a good place, a critical element is ignored in the process of behavioral change: ambivalence (Miller & Rollnick, 2013). As previously noted, when clients are used to others arguing that change must happen, they will naturally take the status quo (i.e., non-change) side of the argument. That is the nature of ambivalence—feeling two ways, sometimes equally, about a behavior and subsequent change. The third component of spirit is acceptance. Carl Rogers (1942) was one of the first to illuminate the importance of providing an atmosphere of acceptance within the counseling session. Rogers believed (and confirmed through clinical research) that if certain conditions were provided by the counselor, clients would find the space and courage to access their personal strengths and engage in personal growth. According to Miller and Rollnick (2013), acceptance is a broad term that encompasses four

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components: absolute worth, accurate empathy, autonomy, and affirmation. Absolute worth includes accepting clients as human beings who struggle like everyone else; they have worth by striving to make sense of their lives, relationships, and the world. We are reminded of Yalom’s (2009) advice to young therapists regarding treating clients as “fellow traveler’s through life.” Counselors show absolute worth by joining with clients to help them navigate a difficult road or journey at a time in their lives. Absolute worth is not about condoning poor or inappropriate behavior. Indeed, counselors should confront clients when their behavior presents a risk to self or others. Accurate empathy was considered by Rogers (1942) one of the “core conditions” for healing. Empathy entails taking on the perspective of the client or viewing the world through the client’s eyes (or standing in the client’s shoes), without judgment or ridicule. The power of empathy lies in the fact that clients feel heard and understood, which encourages them to continue exploring their counseling issues. The importance of empathy to MI was underscored when I (TFL) was in doctoral school. I had an opportunity to contact William Miller for a research paper I was writing for a counseling techniques class. I asked Miller several questions about MI, including, “What is the most important component of MI?” He responded by stating that all parts of MI are important, but if he were pressed it would have to be empathy. Without it, MI cannot be done. Being empathic with clients, of course, is not endemic to MI. Empathy is a foundational counseling skill and is taught in all beginning technique/skill classes within counselor education programs. Demonstrating empathy is a skill of which every counselor should be proficient, no matter the counseling theory or approach. In MI, however, empathy is given a premium role, where the counselor emphasizes reflective listening over questioning. Empathy also entails more than a cursory understanding of the client’s situation. Accurate empathy necessitates reflecting a profound and deep understanding of the client’s predicament and view of self, others, and the world. Autonomy, the third component of acceptance, is another central concept to MI spirit. Recall that a key goal in using MI is to lower the level of resistance/discord between the counselor and client. Skillfully stressing personal autonomy is an excellent way to accomplish this goal. Many clients attend counseling with the expectation that they are going to be told what to do and generally have little or no say in their own treatment. In MI, the emphasis shifts from the counselor telling the client what to do to the counselor emphasizing that it is the client, and only the client, who can make a change. No one can make the change for him or her. Stressing autonomy is simple but profound. When analyzed further, it is difficult to argue with the idea that, with some exceptions, people are responsible for their own life direction. Clients may throw out all kinds of reasons why they do not want to change a problematic behavior and

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confidently state that nobody can make them change. Instead of forcing clients to change, which is impossible, MI clinicians state the obvious by saying a version of the following: “You are right. How you use this counseling and the changes, if any, you choose to make are entirely up to you. No one else, including me, can make you change.” Such a statement has two important effects. First, the client’s defenses are reduced because he or she is no longer fighting with the counselor. Second, the client feels a sense of freedom from having to follow the orders of someone else yet again. He or she is responsible for any change they wish to make. Some may argue that clients don’t always have a choice, that circumstances and contextual factors complicate the expression of autonomy and the clinical picture. The point is well taken. From an MI perspective, however, personal autonomy can still be reinforced, even within difficult circumstances. MI clinicians help clients explore the courses of action that best fits their positive life goals, but underscore that it is the client, ultimately, who makes the final decision. In Chapter 2, we will cover autonomy in greater detail and how to ethically infuse this perspective within the CMHC session. The final component of acceptance is affirmation. Affirmation entails acknowledging and supporting client strengths and positive characteristics. This is more than giving someone a compliment. Rather, the counselor actively seeks to notice positive attributes within the client, affirm their existence, and bring them to awareness. Clients often attend counseling with so-called “problem-dominated stories”; their life script (or situational problem) is conceptualized in negative, self-defeating terms. Certainly, there is truth to the misery clients may be experiencing. Affirmations are designed to directly counter this narrative and point out positive characteristics, such as perseverance, discipline, courage, and desire to be a good (mother, father, partner, brother, sister, etc.). Affirmations awaken latent strengths and use them to lean on when needed. In our clinical experiences, clients are often unaware of their strengths; having someone genuinely point them out can be a powerful and moving experience. More will be said about affirmation strategies in Chapter 2. The fourth and final component of MI spirit is compassion. In this context, compassion is having a genuine interest in promoting the welfare and acting in the best interests of the client. In their original conceptualization, Miller and Rollnick (2002) did not identify compassion as a part of MI spirit. However, as MI has evolved, Miller and Rollnick (2013) realized that anyone in a relationship not only can demonstrate the first three components (collaboration/partnership, evocation, and acceptance) but also can show no regard or care for what happens to the other person. For example, I (TFL) recently went shopping for furniture to accommodate my small private practice. The sales associate greeted us in a pleasant manner and took time to explore what I wanted (collaboration), asked about my perspective on design and color (evocation), and conveyed that

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whatever I decided, he was here to help (autonomy). However, he also was trying to make the sale, and one might wonder if he had a genuine interest in promoting our welfare and best interests. Although I do not believe the salesperson was mean spirited, it is easy to see that, without compassion, counseling may become like a sales negotiation (where the counselor argues for change) in which the best interests of the client may not be a priority. We can certainly attest to the power of MI spirit in our own counseling as it can serve as a foundation for all good therapeutic practice. MI spirit can assist as a good “check” when the counselor and client are not on the same path. Asking, “Could I be more collaborative?” “Could I elicit more from the client?” Could I show greater empathy?”, and “Am I conveying compassion?” are good queries for counselor self-reflection. In addition, the technical elements of MI, if used outside the spirit of the approach, turn counseling sessions into technical exercises that may not be very impactful or meaningful to the client. With MI spirit as a foundation, we now turn to additional elements of MI philosophy, principles, and clinical stance.

Philosophy, Principles, and Clinical Stance Clients who are forced, coerced, or otherwise mandated to attend counseling often have little motivation to change. DiClemente and Prochaska (1998) developed the transtheoretical (i.e., Stages of Change) model, where such clients are considered precontemplative in that they are not yet ready to change and do not see a need for change. They may see counseling as a waste of time and the only reason they attend is to appease someone else. The next stage in the model, contemplation, is where clients may see a need for change and even feel some ambivalence about change, but it is still high on their priority list. Within the subsequent stages of change (determination, action, maintenance), motivation typically expands as clients feel more energy about making changes. The transtheoretical model was a helpful starting point for answering my (TFL) question about how counselors should intervene with unmotivated clients. I became more aware that all the theories and techniques we were learning in school were designed for clients who wanted to be in counseling, who wanted to change, and who were willing to put in the time and effort to make positive changes in their lives. Unfortunately, at least in the substance abuse field, about 20% of clients fall into the latter stages of change (determination, action, maintenance) (DiClemente & Prochaska, 1998). We surmise a similar percentage among mental health clients in general. The remaining 80% are firmly in the “precontemplation” or “contemplation” stages of change (DiClemente & Prochaska, 1998). In other words, the theories and techniques we were learning assume clients are ready to act; however, most clients are not ready to

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act, and counselors who ignore this reality may be prematurely applying theoretical interventions before the client is ready. The mismatch between a counselor’s technique and the client’s stage of change can be one factor that contributes to client resistance and/or discord. MI, then, is guided by a set of underlying principles designed to respect wherever clients related to change (Miller & Rollnick, 2002). They encompass an underlying clinical philosophy and speak to the “stance” a clinician assumes when using MI. These principles are directly related to the goals of MI mentioned previously. Motivational Interviewing Principles The first principle of MI is to avoid argumentation. At first glance, this principle may seem obvious to readers: It’s not a good idea to argue with your clients! However, argumentation does not always mean overtly raising one’s voice and yelling at each other in frustration. Arguing can take more subtle forms, such as insisting that the client follow through on your directives, prematurely focusing on a topic, taking things personally, or through negative body language such as tone of voice and physical presence. The idea behind this principle is that arguing, even in subtle ways, can engender opposition, defensiveness, and discord. Clients often react to argumentation by “digging in their heels” and closing off to possible avenues for change. To counter argumentation, MI adopts a more gentle, persuasive style (Miller & Rollnick, 2002) based on the components of MI spirit. The second principle is rolling with resistance. Effectively working with client resistance was a major impetus for the development of MI; older forms of substance abuse therapy were essentially ineffective with their in-your-face, break-down-denial styles of confrontation. With MI, the client is seen as an ally and ambivalence to give up a problematic behavior is understandable. MI counselors roll with resistance by using reflective statements, offering (not telling) new perspectives, and demonstrating empathy (Miller & Rollnick, 1991).1 The third principle of MI is expressing empathy, an essential and defining characteristic (Miller & Rollnick, 1991). Empathy was discussed at length earlier and will be a consistent topic throughout the text. The fourth principle of MI is developing discrepancy. Although MI is not considered an overly confrontational approach, it does allow for clinicians to gently confront clients, and this is typically done through creating and amplifying discrepancies between attitudes, values and/or goals, and behavior. Developing discrepancies rests on the assumptions of cognitive dissonance, first proposed by Leon Festinger (1957). According to Festinger, we are compelled internally to hold our attitudes and goals in harmony with our behavior. When there is inconsistency with this harmony (dissonance), we feel motivated to change to reduce or eliminate the dissonance.

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MI clinicians create cognitive dissonance by pointing out discrepancies between how the client is behaving and inherent values/goals. An example of developing discrepancies is illustrative. When I (TFL) was counseling a client struggling with alcohol addiction, I was struck by the contrast between what the client stated was important in his life and his dangerous levels of drinking, consuming up to 16, 12-oz cans of beer a day. The client continually mentioned how he loved his family, wanted to be a good father to his kids, and did not want to lose his job (which he was at risk of losing), and at the same time was literally drinking himself to oblivion. I gently pointed out (i.e., illuminated) the stark contrast between what he valued and his behavior, showing curiosity in what seemed obviously incompatible. The client, of course, could not make sense of this discrepancy, but he did acknowledge that the obvious answer was to change his behavior to better match his values and what he considered important in his life. Developing discrepancies increased his awareness and heightened his need for change. One last comment about developing discrepancies. It is sometimes difficult to understand how a client can be so unaware of the connection between their attitudes, values and goals, and behavior. However, in the throes of an addiction or some other undesirable behavior, there can be cognitive mechanisms in place that internally block the client from seeing the inconsistency and disharmony in his life (Hettema, 2009). MI assists in “pulling back the veil” so that clients can see that how they are behaving is not consistent with what is important to them. This insight can be a powerful process leading to internal change. The fifth principle is supporting self-efficacy. Self-efficacy is defined as the innate belief in one’s ability that he or she can accomplish life goals (Bandura, 1982). In MI, clinicians try to increase the client’s perception of their ability to change and highlight, plan for, and address any barriers on the path to change (Miller & Rollnick, 1991). Beyond simply recognizing the need for change, which is an important first step, MI clinicians reinforce client hope, optimism, and change language. Other ways to increase self-efficacy include discussing previous successes, connecting with others who have successfully changed, and establishing a supportive change community. The five principles were given greater emphasis in earlier writings on MI. In more recent writings (e.g., Miller & Rollnick, 2013), they are discussed less as five distinct principles and more as ideas that are integrated throughout the MI process. We believe that they are still important and serve as a nice summary of the philosophy behind the approach. Where Does MI Fall? Direct, Guide, or Follow At the risk of oversimplifying, mental health counseling generally includes three communication styles: Directing, guiding, and following (Miller & Rollnick, 2013). The directing style includes telling the client what he or

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she should do and providing advice. The following style includes active listening and allowing space for the client to share, but not providing direction or advice. The guiding style sits between directing and following: The counselor provides some direction, but not without client input. In addition, the counselor follows, but gently provides direction when needed. The guiding style is characterized by assisting, encouraging, and accompanying the client along the path to change (Miller & Rollnick, 2013). MI is consistent with the guiding style and is best suited for clients who are struggling with change (Miller & Rollnick, 2013). This is because the guiding style considers ambivalence an important part of behavior change: Counselors who use too much direction do not understand both sides of client ambivalence and may lose the client. Counselors who use too much following leave clients stuck in ambivalence and nothing is resolved. The guiding style respects ambivalence and shepherds the client toward making (or not making) a change. This is not to say that direction and following are never used in MI. Clearly, if a client is considering something drastic, such as harming self or others, more direction is needed. Clients in the throes of an emotional crisis do not need a guide but rather someone to allow them to tell their story. However, when behavior change is at issue, the guiding style is optimal. In addition, the guiding style is aligned with MI spirit: “We are in this together (collaboration), I’ll try to elicit the ‘why’s, what’s, and how’s’ from you (evocation), I’ll respect you as a human being and your potential for growth (acceptance), and I have a genuine interest in promoting your welfare and best interests” (compassion).

Clinical Mental Health Counseling and Motivational Interviewing So, now that you have had an introduction into the philosophy and spirit of MI, what does this approach have to do with CMH practice? It turns out that the principles, philosophy, and skills of MI are closely aligned with many of the values, functions, and roles of CMH counselors. In this section, we review the principles of CMH counseling and the functions and roles of CMH counselors. We then look at how MI can be a natural fit within CMH counseling settings. Clinical Mental Health Counseling CMH counselors are found in several settings, including community mental health agencies, college counseling centers, private practices, schools, behavioral health care organizations, hospitals, employee assistance programs, and addiction treatment centers (Fuenfhausen et al., 2017). Within each of these settings, mental health counselors wear many

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hats and engage in a variety of roles, depending on the agency’s scope of practice. Common activities include evaluation, screening, assessment, treatment planning, diagnostic interviewing, and case management. The foundational principles of professional counseling, of which CMH is a subspeciality, guide CMH counselors in their work. According to Fuenfhausen et al. (2017), these principles include 1. 2. 3. 4. 5.

Mental health is conceptualized through a wellness lens. Humanistic oriented rather than disease oriented. Emphasis autonomy, personal responsibility, and self-care. Focus on personal strengths and what is working. Client empowerment.

CMH counselors also operate from a more developmental than pathological perspective. In other words, CMH counselors believe that all mental and emotional problems have at least some connections to development. For example, assume a client comes to counseling complaining of low mood, low energy, poor sleep, and loss of appetite. A pathological viewpoint would assume there is something wrong with the client’s brain and neurotransmitter system that is causing these feelings of depression. Primary treatment would include psychotropic medication, possibly combined with cognitive-behavioral therapy. Further assume that the client has just entered retirement after a long, successful, and intense career. She fnds herself bored in her day-to-day activities. She knows that retirement is supposed to be the “golden years” but fnds it a very diffcult transition. From a developmental viewpoint, it is normal to experience these feelings during a common developmental milestone in life. Treatment in this context would include helping the client fnd new ways to create meaning, building new relationships, and engaging in behaviors aligned with her values and goals. This is not to say that CMH counselors ignore medication, only that their frst approach is to examine clients’ past and current developmental trajectory to conceptualize common mental health problems. Indeed, counseling along with medication management may be the best course of action for some clients. Clinical Mental Health Counseling and MI Alignment Many of the principles of CMH counseling and roles of CMH counselors align with the values and principles of MI. For example, the five principles of professional counseling (and CMH counseling) listed previously are consistent with MI’s focus on autonomy and personal responsibility, personal strengths, and empowering the client. MI’s humanistic stance is consistent with CMH counseling’s emphasis in person-oriented care. In addition to alignment of principles, many of the therapeutic behaviors that CMH counselors engage in are consistent with the skills and

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clinical activities of MI. Both CMH and MI oriented counselors focus on relationship building as the critical factor in helping clients change. The first process of MI, engaging, includes basic skills designed to build rapport and strengthen the client–counselor relationship. Assessment is another important skill/activity that CMH counselors engage in within CMH settings. In MI, the assessment of motivation level and the frequency and depth of change talk set the stage for interventions designed to increase or build upon intrinsic motivation. CMH counselors explore and set therapeutic goals with clients on a continual basis. In MI, goal setting is a collaborative activity in which client and counselor explore goals, identify behaviors aligned with goals, and assess barriers to goal accomplishment and how to overcome them. Treatment planning, an activity that typically follows a clinical assessment, is completed by CMH counselors to provide a roadmap for the thoughts, behaviors, and relationships needed to maximize treatment success. Although MI does not specifically follow a model for treatment planning, the approach is designed to prepare clients for treatment planning. Planning, the fourth process of MI, focuses on strengthening commitment to change and envisioning what change may look like. MI makes an important contribution to all these clinical activities; namely, they are conducted in collaboration with the client. We will say much more about the collaborative nature of MI, along with other key principles and skills, in the chapters that follow. Other key roles that CMH counselors engage in include individual counselor, group counselor, and clinical supervisor. Much of the information in this book applies to counselors working one on one with individual clients. We also have specific chapters designed for using MI in group settings (Chapter 6) and as a clinical supervisor (Chapter 8).

Summary We hope that by now you can see how MI can be a natural fit within CMH agencies. In general, we believe this fit can manifest in two primary ways: As an approach used by CMH counselors in individual/group formats and with supervisors in a supervision context and as an agencywide philosophy from which all staff operate. In Part II “Applications of Motivational Interviewing in Clinical Mental Health Settings,” we highlight the use of MI for a range of presenting CMH problems and contexts. In Part III “Training and Professional Development in Motivational Interviewing,” we explore how CMH counselors can acquire and maintain adequate training in MI and incorporate the approach as a guiding method for agency staff and overall client care. The scientific support for these guidelines will be featured and, where research is scant, commentary from experts in MI will provide a starting point for our discussions. The components of MI spirit, collaboration, evocation, acceptance, and

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compassion will serve as the foundation from which all clinical descriptions, techniques, and recommendations are based. Activities and Resources 1. Identify an area within MI spirit in which you would like to be more intentional about incorporating. Make a commitment to act on this component within your counseling sessions. 2. In your counseling practice, identify times in counseling sessions (such as by recording sessions or via supervision) when you were directive, using more of a guiding style, or were more in the following camp. Where do you spend most of your time? How did the client respond to each style? If you were to improve at guiding, what might you do differently?

Note 1. The term “resistance” has been challenged in more recent MI literature. Instead, some MI practitioners prefer the term “discord,” reflecting a relational problem between the counselor and client of which the counselor has considerable control. More about resistance/discord will be discussed in Chapter 2.

References Arkowitz, H., Miller, W. R., & Rollnick, S. (2015). Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122–147. DiClemente, C., & Prochaska, J. (1998). Toward a comprehensive, transtheoretical model of change. In W. Miller & N. Heather (Eds.), Treating addictive behaviours. Plenum Press. Edwards, E. J., Stapleton, P., Williams, K., & Ball, L. (2015). Building skills, knowledge and confidence in eating and exercise behavior change: Brief motivational interviewing training for healthcare providers. Patient Education and Counseling, 98, 674–676. Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press. Fuenfhausen, K. K., Young, S., Cashwell, C., & Musangali, M. (2017). History and evolution of clinical mental health counseling. In J. S. Young & C. Cashwell (Eds.), Clinical mental health counseling: Elements of effective practice. Sage. Hettema, J. (Producer), & Langdon, L. (Director). (2009). Motivational interviewing training video: Instructional information and demonstrative clinical vignettes, a tool for learners. Langdon Productions Keeley, R. D., Brody, D. S., Engel, M., Burke, B. L., Nordstrom, K., Moralez, E., Dickinson, L. M., & Emsermann, C. (2016). Motivational interviewing improves depression outcome in primary care: A cluster randomized trial. Journal of Consulting and Clinical Psychology, 84, 993–1007. Kohn, A. (2018). Punished by rewards: The trouble with gold stars, incentive plans, A’s, praise, and other bribes (3rd ed.). Houghton Mifflin.

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Locke, E. A., & Schattke, K. (2018). Intrinsic and extrinsic motivation: Time for expansion and clarification. Motivation Science. Advance online publication. http://doi.org/10.1037mot0000116 Marker, I., & Norton, P. J. (2018). The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis. Clinical Psychology Review, 62, 1–10. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior (1st ed.). Guilford. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). Guilford. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford. Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64, 527–537. Rath, T. (2015). The only type of motivation that leads to success. Fast Company. Retrieved from www.fastcompany.com/3047370/the-only-type-of-motivationthat-leads-to-success Rockafellow, B. D., & Saules, K. K. (2006). Substance use by college students: The role of intrinsic versus extrinsic motivation for athletic achievement. Psychology of Addictive Behaviors, 20, 279–287. Rogers, C. R. (1942). Counseling and psychotherapy: Newer concepts in practice. Houghton Mieelin Company. Rollnick, S. (2010). Motivational interviewing for mental health disorders. PESI Continuing Education Seminars. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. Guilford. Rubenstein, D. (2016). Application of motivational interviewing in working with psychotic disorders. In B. Pradhan, P. Narsimha, & R. Shanaya (Eds.), Brief interventions for psychosis: A clinical compendium (pp.  103–118). Springer International. Steinberg, M. P., & Miller, W. R. (2015). Motivational interviewing in diabetes care. Guilford. Yalom, I. D. (2009). The gift of therapy: An open letter to a new generation of therapists and their patients. Harper-Perennial.

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Skills and Technical Aspects of Motivational Interviewing

Introduction In Chapter 1, we provided a broad overview of the philosophy and spirit behind motivational interviewing (MI). We think of the spirit of MI as its foundation. Just as a new home needs to rest on a solid foundation to stay vertical (i.e., to “function” as a home), MI spirit is the grounding from which all the technical aspects and skills are used to build motivation to change. If the technical skills are used without this underlying mindset (or, as Miller and Rollnick (2013) stated, “heartset”), then MI becomes overly technical and may be likened to a trick. With this backdrop of spirit firmly established, we feel that it is appropriate to move on to the more technical aspects of MI. Although MI spirit can provide a guiding philosophy for the clinical mental health (CMH) counselor, it may not be enough to help clients find and increase their motivation, reduce ambivalence, and make positive changes in their lives. In this chapter, we expand on Chapter 1 by discussing and illustrating some of the key techniques and skills that support MI practice, consistent with MI spirit. It is important to note, however, that although the combination of MI spirit and MI skills paints a more complete picture of MI in action, you need to understand two other important components of MI: change talk and the four MI processes. These topics will be the foci of Chapters 3 and 4, respectively.

OARS+I: The Foundational Skills of Motivational Interviewing The basic skills of MI spell the acronym OARS+I, which stands for open questions, affirmations, reflections, summary, and information exchange. Of course, the developers of MI did not create OARS+I; they are basic helping skills that are taught in any first-year counselor training program. However, within MI practice, these skills are given emphasis and priority over other basic techniques and strategies. In addition, OARS+I are used intentionally and strategically toward the overall goals of MI: to reduce discord, increase intrinsic motivation to change, and resolve ambivalence. DOI: 10.4324/9781351244596-3

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For example, the strategic use of reflections can invite clients to go deeper into their own change talk, which helps to resolve ambivalence. We expand on each of these skills below. Open-Ended Questions Open-ended questions (or open questions) usually begin with the words “What” or “How” rather than “Did” or “Do.” Open questions invite the client to expand on a topic and can be perceived as less threatening and judgmental than closed-ended questions. For example, the open question, “Tell me more about a typical week of drinking for you” would engender less resistance than “Did you drink this weekend?” In the former, the client is encouraged and invited to talk more about a recent episode of drinking, whereas with the latter he or she may feel interrogated or judged. This is not to say that MI clinicians never use closed-ended questions; however, on balance they are encouraged to ask more open-ended questions relative to closed-ended questions. Recall from Chapter 1 that MI generally falls between the styles of directive and following, what Miller and Rollnick (2013) have called guiding. Open questions are what a good guide uses to shepherd the client toward a consideration of change (or not change, depending on choice; Rollnick, 2010). Open questions need not be complex, but rather curious, respectful, and simple. Examples include “What worries do you have about your symptoms?”, “How would you like to go about making this change?”, and “What would you like to focus on today?” Open questions also can begin with the word “tell”: “Tell me more about that” or “tell me how you came to that decision.” When I (TFL) teach counseling students about the use of open questions, the inevitable conundrum comes up: When students use open-ended questions, some clients do not respond by sharing more information. Sometimes they just give one-word answers as if a closed-ended question was used. It is certainly true that counselors could ask all the open questions in the world and some clients may not share that much. However, open questions are not a panacea that will inevitably lead nonverbal clients to talk. They are used strategically to encourage clients to share more about their hopes, dreams, attitudes, and perspectives. Open questions are part of the overall counseling style in MI, and that is what is important here. In other words, as a sole technique, open questions may not generate much talk (although this is unusual), but if the counselor keeps consistent with the style, the odds are that over time the client will feel less discord and begin to share more of his or her story. Another consideration with open questions is how easily counselors can fall in the trap of intentionally asking an open question, but instead it comes out as a closed question, presumably out of habit. Consider these examples:

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WHAT COUNSELOR SAYS: Can you tell me more about your drinking? COUNSELOR’S INTENTION: Tell me more about your drinking. WHAT COUNSELOR SAYS: Are you sure you want to do that? COUNSELOR’S INTENTION: What are your thoughts about that?

The frst and third questions are closed questions. Beginning questions with “Can” or “Are” invites a one-word response. Simply dropping the “Can” and rephrasing the third example invites clients to share more about the topic of interest. Affirmations Affirmations were introduced in Chapter 1 and described as part of the MI spirit component of acceptance. Technically, affirmations are a form of reflective listening, but designed to anchor clients within their strengths, positive characteristics, and resources as they address problems. Affirming is a quiet, genuine acknowledgment of strengths. The use of affirmations, however, is delicate. Rosengren (2018) noted how clients can sometimes feel judged or patronized after an affirmation. To mitigate this potential, he suggests counselors should: (a) Focus on specific behaviors and internal attributes instead of decisions or goals. (b) Avoid using “I” (e.g., I think .  .  .). Using “I” to begin an affirmation puts the focus on what the counselor thinks, rather than client strengths. A consistent recommendation is to begin affirmations with “you,” which places observations squarely within the client and is more difficult for the client to dismiss (Rosengren, 2018). (c) Reflect on this question, “What are some interesting qualities that the client possesses?” (d) Embrace a strength-based rather than deficit model of clients. Rosengren (2018) suggested that affirmations are probably the most underutilized of the OARS, and we unfortunately agree. There is even some evidence that the proper use of affirmations increases the likelihood of change talk (Apodaca et al., 2015). We strongly encourage mental health counselors to utilize affirmations if they are genuinely felt. They can substantially shift the tone of a session, remind clients that they do have strengths, counter negative self-narratives, and, as preliminary research suggests, promote envisioning change. As with any technique, however, affirmations should not be used liberally in sessions, lest they come across as bogus. Aim for one to two affirmations per session. Table 2.1 lists some examples of affirmations. Notice how each starts with the word,“you” and the focus is on one or two strengths.Affirmations are not the same as praise. As with “I” statements, praise connotes a nonegalitarian relationship in which the expert therapist casts approval of

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Table 2.1 Examples of Affirmations Contrasted with Praise Affirmations

Praise

You have shown a lot of resolve in the past two weeks, with everything that has gone on. You just want to be the best father you can be. Just by coming here, you have shown strength and courage to tackle your struggles. You say discipline is not your thing, and yet you have shown a lot of discipline the past couple of days. You have a knack for making the right decision for you. With all that has been going on, you were able to keep strong. And that is just it, when you set your mind to something, you follow through!

I think your resolve has been great. I really approve of the way you handled that with your children. Nice job coming here! You say discipline is not your thing, but I think you have shown it the past couple of days. I think you made the right decision. Bravo! I like the way you were strong! I like that! Way to go!

the client. In Table 2.1, we contrast affirmations with praise to help readers better understand the difference. Reflections Reflective listening is a key skill when practicing MI. In fact, without ample reflective listening, one cannot apply MI. Reflective listening is nothing new to mental health counselors; what is unique to MI, however, is how reflective listening is incorporated into the practice. The skill is used with intention, and the balance of counselor utterances should be reflections. The general recommendation is a 2:1 ratio of reflections to questions (Cole, 2008; the “gold standard” is 3:1, but that can be quite difficult to achieve)! When I (TFL) teach students that there should be twice the number of reflections as questions, a common response is “that’s not too difficult.” In practice, however, keeping this balance is easier said than done. In just a little time of practicing MI on their own, students come to realize that the “pull” to ask questions is very strong and reflecting more often presents more challenge than they had anticipated. So, why does MI focus so much on reflections? Keep in mind one of the overarching goals of MI is to reduce discord and resolve ambivalence. Reflective listening is one of the best ways to convey empathy and is nonthreatening. Client defenses are softened when counselors respond with less interrogation (i.e., questions) and more reflection. You are unlikely to do any harm with reflective listening. This is not to say that questions are not important; as noted earlier, they are critical to gathering information

22 Foundations of Motivational Interviewing and moving things along. But sometimes a line of questioning, especially without any reflections in the mix, can feel like judgment, only to increase discord and resistance. In our experience, a powerful observation is when a reflection “hits the mark” and conveys exactly what the client meant or feels. It is difficult for the client to resist such understanding. Let’s take a brief look at what, exactly, constitutes a reflection. Reflections seek to summarize what a person means. It is not unlike making a hypothesis. Critically, reflections are not questions but statements. The distinction is not trivial; consider the following two comments and their possible effect on client response: CLIENT: I am just mad! How can they make COUNSELOR RESPONSE #1: You are angry at

such changes on a whim? what is happening at work (stated matter of fact; no voice inflection at the end) COUNSELOR RESPONSE #2: You are angry at what is happening at work? (Voice tone gets higher (inflection) at the end) The first response is a reflection. The counselor captures the client’s emotion of anger based on what is going on at work. The likely response from the client is a nod of agreement and an expansion of his employment struggles. The second response is a question. Take a moment and ask yourself this question, raising your voice at the end. It is difficult not to come across as critical when doing so. The underlying message is, “I can’t believe you are angry at work. You shouldn’t be angry, and this surprises me.” If the client does take away this message, he or she will feel invalidated. Skillful use of reflections helps move narratives forward and encourages continual conversation about what is troubling the client. At the risk of oversimplifying, there are two general types of reflections: simple and complex. A simple reflection includes paraphrasing what the client just communicated. A complex reflection adds meaning to the client statement, such as an underlying emotion, body language, facial expression, and so forth. In response #1 above, the counselor used a simple reflection to paraphrase what the client is feeling. Note how no new meaning was added—it was just a simple way of conveying to the client “I got it.” Here would be an example of a complex reflection: COUNSELOR RESPONSE #3:

Making changes without consulting you is upsetting, and I imagine this hurts your morale.

In response #3, the counselor offered additional meaning to the client’s original statement: The counselor suggests that the client is upset because management is not consulting him about important changes. In addition, the counselor hypothesizes the client’s morale has been impacted. The counselor strategically deepened the client statement to get at underlying thoughts and feelings that were not directly expressed.

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The reader may be thinking, “Whoa, hold on.” The client said nothing about low morale. “Aren’t you just manipulating the client by suggesting something he did not say?” Whereas this concern is understandable, it is minimized by stressing client autonomy. That is, the counselor can make a guess as to what the client might be feeling or thinking and, if it is off the mark, the client has the autonomy to provide a correction. For example, if the counselor’s reflection above was not accurate, the client might respond, “Well, my morale is actually pretty good, it’s just I wish I could deal better with management and my anger.” The counselor then has a more accurate view of how the client is feeling and can use this information moving forward. When a reflection is accurate, the client will indicate so via facial expression, body language, and/or continued discussion; indeed, accurate reflections can be a powerful way to build empathy, as if the client says, “Yes! That is exactly how I feel!” With autonomy, the client has the power to direct the conversation based on whether the counselor’s reflections are accurate or not. OTHER TECHNICAL ASPECTS OF REFLECTIONS

As noted earlier, mental health counselors should aim for a ratio of two reflections for every question. Doing so avoids the “question and answer trap” (Miller & Rollnick, 2013) which predictably engenders more discord and resistance. The question-and-answer trap is likened to the steady volley of a tennis ball back and forth over the net, with no real movement or progress in the match. How frustrating that would be to watch! For example, the counselor asks a question and the client responds. Instead of responding with a reflection, the counselor asks another question and the client responds again (the “volley” back and forth). While the counselor may have good intentions to gather information by asking questions, the client begins to feel uneasy, as if he or she is under a legal examination. In the meantime, significant time has passed, the counselor and client have made little clinical progress, and the client feels unheard. Trapped is an apt description of what the counselor may feel by relying too heavily on questions. In addition to the target ratio of reflections to questions, the depth of a reflection should match the clinical situation. For example, at the beginning of a session or with a new client, simple reflections are probably best. Simple reflections also are best toward the end of a session, where offering new hypotheses or adding meaning to client statements would not allow enough time for processing. Within the middle parts of a session (as the client shares more), the counselor can gently increase the depth and complexity of reflections. In situations where the client is struggling with intense emotions, sticking with simple reflections is probably best (using more of a following, rather than guiding, style). As rule of thumb, the less the counselor knows what a person means, the shorter the jumps in interpretations should be.

24 Foundations of Motivational Interviewing There has been some clinical debate about the usefulness of bridging statements to “set up” a reflection. Bridging statements are comments used before a reflection such as, “So, it sounds like . . .” or “So, what you are saying is . . .” In many counselor training programs, students begin using these bridging statements from their first techniques course; they become a fallback when the counselor is nervous and a habit that is difficult to break. Whereas there is nothing technically wrong with using bridging statements, our view is that they are not necessary. Overuse of these statements runs the risk of sounding annoying to clients. Crisp, direct reflections, especially when they are on target, can be more impactful with clients. Consider three examples, one with a bridging statement and the other two without. Example #1: So, it sounds like what you are saying is that you are angry with what has happened at work. Example #2: You are angry with what has happened at work. Example #3: You are angry. In example #1, the counselor uses a reflection to convey an understanding that the client is angry. However, with the bridging statement, the reflection becomes awkward and loses some of its impact. In example #2, the bridging statement is dropped, making the reflection nimbler and to the point. Example #3 is even more direct. Take a moment to practice these reflections out loud. What did you notice after stating each one? How do you think a client might respond or react after hearing each one? In our MI training, we do not insist that participants drop all bridging statements. We encourage counselors to practice reflections with and without bridging statements and see which method fits the best. It has been our experience that most will find the statements unnecessary, or at least develop greater nuance in how they give reflections. Summaries Summaries include taking time each session to pull together the key statements and themes offered by the client. They serve as a kind of “time out” in the session as the counselor strategically reflects the client’s own ambivalence and change language; in this sense, summaries can be conceptualized as an extended complex reflection. Summaries are a strategic component of MI, and their skillful use can help move sessions forward, generate change talk, and build empathy. Unfortunately, summaries are probably not used enough in mental health counseling work. Yet, this simple strategy can help clients work through their ambivalence. In general, there are three types of summaries, each serving a slightly different purpose (Miller & Rollnick, 2013). A collecting summary has the effect of moving a session forward and is typically offered around

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the middle of the session. A linking summary is designed to develop discrepancy (see Chapter 1) where the counselor, using the client’s goals, information from collaterals (and other sources), and past information, links the discrepancy between what the client holds important (goals) and current behavior. A transition summary is typically offered at the end of a session to transition to the next meeting or to switch directions/topic (Miller & Rollnick, 2013). The types of summaries outlined earlier are useful for didactic purposes; however, mental health counselors should not sweat these differences too much. In practice, mental health counselors may use any combination of summaries in a session or even within a summary. Aim for one to two summaries within each session and include at least two components: (a) the client’s ambivalence about change and (b) any change talk that is offered. Other components of summaries can include the counselor’s own impressions, assessment findings, and statements of affirmation. As the client builds motivation and moves in a direction of change, periodic “grand summaries” can be quite useful to tie things together. Grand summaries are less frequent, such as every few sessions, and can be a valuable link connecting the sessions. After providing a summary, it is useful to follow up with an eliciting question, such as “have I got that about right” or “is there anything you would add.” In addition, because summaries are generally designed to move things forward, asking a “key question” at the end of the summary can engender new directions or insights. Key questions (Miller & Rollnick, 2002) might include: What do you think you will do? I can see you are uncomfortable, hearing this. What is the next step from here? What will you be doing instead of _________? What do you make of what I just said? It sounds like something needs to change. What do you think? How would you like things to be different? Based on what I said, what thoughts come to your mind? Information Exchange Information exchange is a relatively new addition to the basic OARS skills. Providing information can be a way for mental health counselors to clarify facts, processes, and feedback to clients. In our experience, many clients want information to help them better understand what they or their loved ones are going through. In MI, however, information is not provided as unsolicited advice but rather through asking permission first, offering ideas, and being concise and to the point (Rosengren, 2018). Accurate information can enhance motivation, ease anxiety, and help clients develop

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skills needed to be successful. Of course, the skill is an “exchange”, meaning that it is a two-way street (Rosengren, 2018). That is, clients can and do share information about themselves and their healing journey that can help the counselor better utilize interventions. OARS+I are the core skills used in MI to move sessions forward and to engage in the four processes of MI, especially engaging (discussed in Chapter 4; Rosengren, 2018). They serve as foundational skills for eliciting change talk, offering information, and even planning. However, even with the best use of OARS+I, other skills may be needed to remove roadblocks to the change process. Strategies for how to address resistance and discord are next. Handling Sustain Talk and Discord When I (TFL) was in doctoral school, I recall wondering how mental health counselors manage to work with clients who do not want to be in counseling, either by being coerced (e.g., parents making an adolescent go to counseling) or because they are not ready or motivated to change behavior. I remember thinking about the interesting theories we were learning but struggling with how they would work with a “resistant” client. After some exploring and through several classes, I was introduced to MI as a method for handling these issues. Indeed, MI is well-suited to work with clients where motivation is lacking and the client, for whatever reason, does not want to attend counseling. Of course, MI can be quite useful for motivated clients as well, but the method was initially born out of a need to better address client resistance. Resistance Reconsidered As noted in Chapter 1, one goal of MI is to lower resistance within the counseling session. Resistance has an obvious negative impact on successful counseling. Indeed, it is generally accepted that no counseling in the world will work if clients are not committed to the process or the possibility of changing. However, before we continue a point of clarification is needed. MI philosophy suggests that resistance is not conceptualized as something that resides within the individual. Rather, resistance is thought of as a relational phenomenon and that its manifestation is largely the result of the therapeutic relationship between counselor and client. The term resistance has even been dropped in more recent MI literature (Miller & Rollnick, 2013; Miller & Moyers, 2017) and broken down into two observable behaviors: sustain talk and discord (Miller & Moyers, 2017). Sustain talk, a topic we turn to in Chapter 3, includes client language about keeping the status quo (e.g., “I don’t want to quit drinking.”). Discord more accurately reflects counseling situations where counselor and client are not on the same page. Discord means that something between the counselor and client relationship is amiss or just off in some way.

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Traditionally, resistance has been conceptualized as a problem residing within the client and occurs in relationship with oneself (e.g., “following treatment is too hard”; Cole, 2008). Based on Freudian Psychoanalysis, resistance is thought to stem from unconscious blocks within the psyche. It is the therapist’s job to unbind the unconscious and allow for the free flowing of psychic energy. This traditional conceptualization still impacts counseling today as “client resistance” is often given as a reason for lackluster progress. Notice that within this paradigm the counselor is thought to have little influence in the creation of resistance: The client is primarily responsible for his or her own blocks to progress. However, from an MI perspective, sustain talk and discord occurs in the context of relationship (e.g., the treatment is too hard, I don’t want to do it, and you say I must do it!). Sustain talk and discord is very much influenced by what the counselor does in session (Miller & Moyers, 2017). Discord tends to increase when counselor behavior is inconsistent with sound listening skills. Thomas Gordan’s (1970) 12 blocks to listening are good examples of how counselors can engender discord. For example, giving unsolicited advice, although well-intentioned, may be perceived unfavorably by a client and increase his or her tendency to tune out of the counseling session. Counselors who frequently fall back on the “righting reflex” (explained later) are particularly vulnerable to higher levels of discord. MI has made a significant contribution to our understanding of resistance, even proposing new concepts (sustain talk and discord) to better capture the relational elements of the experience. However, our view is that both conceptualizations, resistance and sustain talk/discord can be useful. For example, it is certainly the case that some clients, irrespective of the counseling relationship, have internal blocks to changing that would traditionally fall under the term resistance. In addition, the most ardent practitioner of MI is most likely going to get resistant statements from time to time. Throughout this text, we will be intentional about whether we are discussing resistance (relationship to self), sustain talk (language supporting the status quo), or discord (relationship with other). However, keep in mind that the overall effects of too much resistance, sustain talk, or discord are essentially the same: little progress in counseling. MI counselors strive to minimize discord as much as possible (strategies for minimizing sustain talk are presented in the next chapter). Many MI skills and techniques, as well as the overall spirit of the approach, are designed to accomplish this goal. Stated differently: Almost every strategy in MI is in the service of reducing discord. That may not be the only goal of a technique, but when examining the reasons for an intervention, reducing discord is usually in the mix. We do not want to imply that discord needs to be completely banished. Some amount of discord can be healthy and even desirable (e.g., a client may have legitimate reasons not to take the counselors suggestions). It is when it dominates and overshadows the session that client change becomes unlikely.

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What does discord look like in clinical settings? Discord occurs when the counselor and client are not on the same page; because it is between people, it involves feelings, inaccurate perceptions, and the sense that, somehow, things just aren’t working. Discord is behavior and can occur at any time in the counseling process. Client behavior can manifest as arguing, blaming, interrupting, interpreting prematurely, passivity, or stonewalling. Discord is “lively” in the sense that the counselor can, with a trained eye, easily note its occurrence and shift strategies to help lower its effects. For example, if the counselor senses too much discord in a session, he or she could fall back on the components of MI spirit to strengthen the counseling relationship. Specific Strategies for Handling Discord In general, counselors should try to get a sense of the underlying emotion driving the discord. Remaining in a position of curiosity, extending complex reflections, and exploring discrepancies are general methods to consider. Counselor behavior also needs attention. Although keeping true to MI spirit can go a long way in reducing discord, there are specific strategies that CMH counselors can use in a counseling session. We briefly touch on these below. For ease of presentation, we offer these techniques as strategies to reduce discord, but they can just as easily be used when blocks to change reside primarily within the client (i.e., resistance). AMPLIFIED REFLECTION

Amplified reflection includes a slight exaggeration or increase in the intensity of client statements. When clients make extreme statements or take extreme positions, it is unproductive to get in a quarrel about the merits of the statement. A better strategy is to reflect the statement but amplify the resistant element. The effect is usually a backing off the original extreme position. Here are a couple examples (the amplified parts are underlined): CLIENT:

It would be impossible to make friends if I didn’t drink as much as they do. COUNSELOR: There would be no way you could make another friend without drinking. CLIENT: How many times do I have to fail at this. I am never going to succeed in a treatment program! COUNSELOR: No matter what you try, you will always fall short. In the first example, the client takes the extreme view that she will never make friends unless she drank large amounts of alcohol. This leaves little room for other considerations. With the amplified reflection, the

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counselor reflects the extreme part of her statement; specifically, that the client will not make another friend for the rest of her life unless alcohol is involved. Obviously, this is absurd, and the client response will most likely be a lessening of the original position. In the second example, the client is focused on failure and holds the position that he will never succeed again. Through an amplified reflection, however, this view is exaggerated, where he can see the extremity of his position. Again, the effect is usually a “backing off” of that original viewpoint. Amplified reflections also can be understatements to help clients consider situations more seriously. Here is an example: CLIENT:

I love drinking with my buddies. Just love it. The worst that could happen is getting a DUI or something. COUNSELOR: And getting a DUI is nothing to worry about. Counselors need to be careful with amplified reflections in that they can be interpreted as sarcasm or even hostility, especially with new clients. We recommend using amplified reflections with sufficient rapport. There also is a playful element to these reflections that can even strengthen the counseling relationship. DOUBLE-SIDED REFLECTION

With double-sided reflections, the counselor intentionally reflects both sides of the client’s ambivalence, intentionally ending on the pro-change side. The benefit is that the client can better understand his or her own ambivalence and is encouraged to continue talking about change because the counselor ends the reflection with that focus. Here is an example: CLIENT:

Look, I know I need to curb my anger. But when the kids do something they shouldn’t I just feel I need to let them know I’m serious. It feels good to be in charge like that. COUNSELOR: On the one hand, yelling at the kids exerts your authority, which feels good, and on the other hand you recognize a need to turn down the dial. This reflection captures the client’s predicament about how to better discipline his kids. The likely response is more change talk about the need to better manage his anger. SHIFTING FOCUS

Every mental health counselor has experienced clients who seem to get stuck on specific labels, words, or actions that present stumbling blocks to progress. For example, clients may resort to blaming others for their

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problem and thus continue conversations that do not focus on personal responsibility. Another example is when clients overly focus on whether certain labels accurately describe them as persons, such as “borderline.” Miller and Rollnick (2013) are especially critical of labeling and how it can be counterproductive to the change process. Shifting focus is a strategy to help steer the conversation away from these stumbling blocks so that attention can be placed on resolving ambivalence and behavior change. The counselor, for example, could introduce new areas of concern or gently nudge the client away from a label. Here are a couple of examples (the shifting focus parts are underlined): CLIENT:

Look, I know I have some problems, but at least I am not an alcoholic. Do you think I am an alcoholic? COUNSELOR: How you experience your drinking is something that you will have to decide. Tell me a bit more about what brought you in today. CLIENT: It is all her fault! If she would just stop nagging me all day and let me be, I wouldn’t be so angry. Can you tell her to stop for me? COUNSELOR: I hear you loud and clear that you are not happy with how things are going. What is one thing that you can do to help the relationship? In the first example, the client may be stuck on the label, “alcoholic” and has considerable concern about what the counselor believes. Debating the merits of the label or trying to convince her that she is not an alcoholic may engender discord and stall counseling progress. The counselor strategically shifts focus to center the conversation squarely on the behavior that got the client into trouble. A quick additional note about labeling: Beginning counselors often ask if they can use a word or label if the client uses it. For example, if a client describes himself as an alcoholic, can the counselor use the same term? We do not have any concern using the same words the client uses to describe experiences. However, we caution that overuse of labeling and getting caught in pointless debates about whether the client is or is not something typically contribute to discord. In the second example, the client is stuck in a pattern of blaming others. Going down this path would probably reinforce more blaming and would not allow the client to consider alternative ways to help his relationship. The counselor shifts focus by emphasizing the client’s own role in healing the relationship. EMPHASIZING PERSONAL CHOICE AND CONTROL

When clients feel lectured, forced to take on certain actions, or as if others are telling them what to do, discord results. Client autonomy was discussed in Chapter 1 as part of the MI spirit component of acceptance. Emphasizing personal choice and control is autonomy in action. The

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counselor intentionally emphasizes that nobody can change for the client and only the client can decide. This strategy is simple yet profound; there is a fundamental truth that, in most cases, no one can force another to change. Emphasizing personal choice and control simply entails an overt statement emphasizing that clients have within themselves the ability to choose. In our experience, clients who recognize their own autonomy have a greater sense of freedom and less internal resistance to the counseling (or change) process. Here is an example: CLIENT:

I feel like all these people are pecking at me. They can’t make me stop! COUNSELOR: You are exactly right. Nobody can make you change, even if they really wanted to. What you continue to do with your marijuana use is completely up to you. REFRAMING

Proponents of postmodern approaches to counseling and psychotherapy suggest that clients often present with “problem-dominated” stories. That is, the client is caught in a life script that reinforces problems rather than solutions. Counselors who are overly engaged in these problem narratives tend to reinforce their power, precluding movement in a pro-change direction. Reframing client statements can help to shift the narrative by helping clients see things in a different way and turn negatives into strengths. Using a reframe, the counselor validates the client’s observations, but adds new information the client may not have considered. Here is an example: CLIENT:

Why is she always on my case? It just makes things worse. I feel like I always must please her. I hate it! COUNSELOR: She is really worried about you. I wonder if there is a way to respect that worry while at the same time finding your own space. AGREEMENT WITH A TWIST

This technique is a reflection followed by a reframe. That is, the counselor initially sides with the client, but introduces a new consideration, idea, or possibility, usually pointing toward change. The “agreement” portion conveys empathy and lets the client know that the counselor understands, whereas the “twist” part introduces the new possibility (reframe). Here are some examples, with each part noted in brackets: CLIENT: School is COUNSELOR: You

just pointless and so boring. I should just drop out! are not happy with how school is going [agreement], and yet finishing is something that will help you with reaching your goals [twist].

32 Foundations of Motivational Interviewing I just love using marijuana. It helps me relax and just forget all my problems. COUNSELOR: I can see how using pot is like an old buddy [agreement], even if he keeps on getting you in trouble [twist]. CLIENT:

Agreement with a twist is one of the more complex of the responses discussed here. In the first example, the client is considering dropping out of school. The counselor’s task is to agree with the client that school is not going very well, but then introduce the idea that if the client does not finish, reaching his career goals might be a challenge. This “twist” may lead to a more productive discussion about how the client can stay in school, even if it is not an optimal experience. In the second example, the client appears blind to marijuana’s negative consequences. The counselor reflects by using a metaphor of pot as a friend (agreeing with the client that he indeed loves using), but then suggests that the client is holding on to this friend despite consistently getting him into trouble. We would imagine that the client would respond to this reflection by acknowledging marijuana’s negative consequences and be more willing to engage in a discussion along these lines. COMING ALONGSIDE

The nature of client ambivalence suggests that there are two sides of an argument—the pro-change side and the counterchange (or status quo) side. Clients who are ambivalent about behavior change usually feel energy on both sides of the debate. If a client is asked to only consider one side, the natural reaction is to defend the other side. Stated differently, if a counselor always argues for the pro-change side, the (ambivalent) client will usually defend the counterchange side. In coming alongside, the counselor strategically defends the counterchange side to elicit a defense (or consideration) of the change side from the client. Here is an example: CLIENT:

I know I should do something, but it is just not good timing . . . my two young kids, too many stressors, and too much stuff going on. COUNSELOR: And that is something that is concerning. A program like this does require a lot of motivation and effort, and it is unclear how serious you are about wanting to change. It really wouldn’t be a good use of our time if you are not quite ready to tackle this. So, I hear you that now may not be the right time . . . when would be the right time? Coming alongside should be used strategically as a last resort. In this example, the client continues to show little interest in changing, even after several counseling sessions. Instead of continuing to argue for the client to change, the counselor suggests that the client may not be serious

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about change at this time and queries when the right time might be. The last portion of this intervention is important: If now is not the time, then when? The client is now in a position where she no longer must defend the status quo. With this freed up energy, she may open to the possibility of following through with the treatment program. The previous strategies can help counselors reduce discord when it appears to be impacting change progress. They are not a magic bullet, and there is no guarantee that they will work with every client, every time. However, with consistent use, clients usually feel more open to explore both sides of their ambivalence, feel less struggle to maintain the status quo, and discover new possibilities for change. Discord-Enhancing Traps Miller and Rollnick (2002) outline several clinical “traps” that mental health professionals should avoid early in the counseling process. These traps can put counselors on the fast track to discord. A brief description of each follows. PREMATURE FOCUS

In this trap, the counselor assumes that the client fits neatly into a specific counseling theory or area of focus. It also might occur when the counselor assumes too early that the client is ready to change. For example, the counselor might provide the client homework after the first session, without sufficiently exploring the client’s ambivalence. A predictable outcome is that the client avoids the homework because he or she is not ready. CONFRONTATION-DENIAL

The confrontation-denial trap includes explaining why change is necessary and needs to happen (especially early in the counseling process). Readers should recognize this trap as the exact opposite of the discord lowering strategies discussed earlier. That is, counselors who confront too heavily are taking the change side of the argument without consideration of ambivalence. The usual result from the client is denial and a strengthening of the counterchange argument. LABELING TRAP

Labels include words that define the entire person and are often derogatory, such as “manipulator,” “freak,” “alcoholic,” and even some DSM 5 diagnoses. Labeling is unnecessary for behavior change (Miller & Rollnick, 2013) and in some cases even harmful. Counselors should try to

34 Foundations of Motivational Interviewing avoid labels whenever possible. Shifting focus and reframing client statements into more positive directions are excellent methods for avoiding the labeling trap. BLAMING TRAP

This is an obvious trap to avoid: Counselors should not blame their clients. However, this trap not so much occurs between counselor and client (although that can happen), but within how a client might discuss someone else or during family or couples counseling. It is human nature to look for who is to blame or who is at fault. The problem is that pointing the finger usually engenders discord and discouragement and precludes more productive discussions about behavior change. To avoid this trap, counselors can rely on any of the discord-reducing strategies above. QUESTION AND ANSWER

This common trap was mentioned earlier, and we will not go into more detail here. Suffice it to say, however, that the trap is enhanced if the counselor uses a preponderance of questions to the absence of reflections. To avoid this trap, incorporate more reflections into your practice. EXPERT

When counselors come across as the all-knowing expert, especially as an expert on the client, discord is likely to follow. MI counselors strive for clients to be active in their own change process. The counselor has expertise but is not the expert on the client; clients are experts on themselves. As such, counselors can certainly offer expertise and information; however, within MI this process is followed by seeking the client’s permission. For example, a counselor might say, “As you have been talking, some ideas have come to mind that might be useful. Would it be alright if I share those with you?” After the counselor has shared some thoughts, a simple, “What do you make of that?” allows the client to process the information and see if any of it fits. Asking permission and checking in on the client when information is provided are strategies to avoid the expert trap.

Summary In this chapter, we outlined the key skills and technical aspects of MI used to build rapport, help clients discover intrinsic motivation, and reduce resistance and discord. The impact of these skills and techniques, however, is moderated by the strength of the underlying MI spirit. That is, without the foundation of collaboration, acceptance, evocation, and compassion,

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skills and techniques may ring hollow and not be of much help. Competent MI practice is the synergistic balance between spirit and technique, with each supporting the other. In the remaining chapters of this section, we look more specifically at ambivalence, introduce the concept of change talk, and focus on the use of MI within mental health counseling settings.

References Apodaca, T. R., Jackson, K. M., Borsari, B. B., Magill, M., Mastroleo, N. R., & Barnett, N. P. (2015). Which therapist micro-skills elicit client change talk and sustain talk in motivational interviewing? Journal of Substance Abuse Treatment, 81(1), 35–46. Cole, C. (2008, October). Advanced training in motivational interviewing. Workshop presented by Cathycoletraining, Inc.: Carrboro, NC. Gordan, T. (1970). Parent effectiveness training. Wyden. Miller, W. R., & Moyers, T. (2017). Advanced workshop in motivational interviewing. Workshop attended in Albuquerque, NM, United States. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). Guilford. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford. Rollnick, S. (2010). Motivational interviewing for mental health disorders. PESI Continuing Education Seminars. Rosengren, D. B. (2018). Building motivational interviewing skills: A practitioner’s workbook (2nd ed.). The Guilford Press.

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Motivational Interviewing, Ambivalence, and Change Talk

Introduction Miller and Rose (2009) proposed two hypotheses that account for the effect of counselor use of MI on client change. The relational hypothesis represents the impact of the therapeutic relationship and, more specifically, counselor empathy in session. By establishing a therapeutic environment of acceptance, clients experience the psychological safety and autonomy they need to resolve their ambivalence and make decisions about change. This component is understood as “MI spirit” and was described in Chapter 1. The technical hypothesis is characterized by counselor use of motivational interviewing (MI) skills to evoke and strengthen client language in support of change. Utilizing MI-consistent skills, counselors increase clients’ in session pro-change language and decrease language in support of the status quo or not making a change. This increase in client change talk, and resulting decrease in sustain talk, is hypothesized to account for client change (Miller & Rose, 2009). In this chapter, we will expand on and explore additional technical components of MI, which includes the concept of ambivalence, how change talk and sustain talk are operationalized in MI, and ways in which counselors can evoke and strengthen client change talk in session.

Why People Stay Stuck It is not uncommon for our clients to be ambivalent about change, even in circumstances when their behaviors are destructive or even life-threatening. In MI, ambivalence can be understood as the co-existence of strongly held opposing beliefs about change. In other words, the client holds simultaneously yet conflicting beliefs about changing. The client may recognize the need to change; however, there is also recognition of the advantages of the status quo, and of not changing. Miller and Rollnick (2013) have suggested that ambivalence is not pathological but is a normal human experience. It is natural to experience ambivalence, even when one is committed to making a change. A person who engages in DOI: 10.4324/9781351244596-4

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non-suicidal self-injury may acknowledge the need to change because of the negative consequences associated with self-harming behaviors yet may also recognize that self-harming is a powerful (albeit maladaptive) strategy for emotion regulation. Though normal ambivalence to change can be complex and multifaceted. Zuckoff et al. (2015) argued that in mental health counseling, clients can be ambivalent about their presenting problems as well as the treatment or techniques in counseling used to address the problem. Making ambivalence even more complex is that, according to Naar and Safren (2017), an individual’s motivation to change can fluctuate over time and can vary on the basis of the specific problem that is being addressed in counseling. A client may be highly motivated to make a change immediately following an unsettling or negative event, but the client’s motivation may dissipate as the memory of the event fades over time. Further, clients may have differing levels of ambivalence for various treatment goals. Whereas a client may be very motivated to explore anxiety-provoking obsessive thoughts; the client may be more hesitant about modifying compulsive safety behaviors that are used to reduce the intensity of those distressing thoughts. Given that clients often present to counseling with multiple problems, it is necessary to explore ambivalence related to working on each treatment goal (Naar & Safren, 2017). Finally, what also contributes to the complexity of ambivalence, and may help explain why some clients remain stuck, is that they may not realize they are ambivalent about change. Westra (2012) observed that some individuals who come to counseling to treat their anxiety may not recognize or even understand the disadvantages of making a change. Engle and Arkowitz (2006) identified several cognitive, affective, and behavioral signs of ambivalence to help counselors identify it in counseling. These signs include (a) the client understands that change is in their best interest, (b) the client possesses adequate information and capacity to change, (c) the client’s language and behavior indicate movement in the direction of change, (d) the client’s language and behavior also indicate movement away from change, and (e) the client experiences a negative emotional response to not changing (Engle & Arkowitz, 2006). Despite the unpleasant affective reaction brought about by being in a state of ambivalence, clients do not change for several reasons. Although problematic, the behavior or way of being may serve an important role in the client’s life, and by extinguishing it the client also loses the positive reinforcement or rewards that it produces. Further, it can be safer or more comfortable for clients to maintain their current patterns of behavior and thinking, regardless of the distress caused by them, than it is to face the uncertainties and potentially daunting new challenges associated with change (Engle & Arkowitz). For example, the premise of behavioral activation in the treatment of depression (Mazzucchelli et al., 2009) is relatively simple (i.e., decrease isolation and avoidance by increasing

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engagement in activities that improve mood); however, the process of increasing the frequency of behaviors that are pleasurable or result in mastery experiences involves a number of steps (e.g., self-monitoring, activity scheduling, and structuring) that can be quite overwhelming for some clients with depression. Clients also may wish to remain in the status quo over changing because they are fearful or anxious that if they fail, they will feel worse (i.e., increased shame and guilt) about themselves (Engle & Arkowitz). As changing deeply entrenched patterns can be very difficult, this fear is understandable. The behavioral inertia associated with ambivalence has commonly been understood in counseling as resistance (Engle & Arkowitz, 2006; Westra, 2012). Client noncompliance or avoidance behaviors in session may reflect fears or beliefs about changing the status quo. Engle and Arkowitz (2006) posited that ambivalence in counseling is a byproduct of the relationship between the client and counselor, not a fixed trait of the client. Therefore, the counselor plays a critical role in helping clients resolve their ambivalence. Ambivalence may be a “safe” place to be, in that any change or disruption of the status quo can result in increased uncertainty; however, holding two opposing beliefs over time can itself be uncomfortable (Festinger, 1957). Counselor responses to client ambivalence can heighten it, thereby maintaining the client’s “stuck-ness,” or can guide clients in choosing a path forward, which can alleviate the pressure associated with having two dissonant beliefs. Ambivalence Meets the Righting Reflex When presented with a client who is ambivalent about changing a problematic behavior, it is natural for a counselor to want to call attention to the client’s problem and need to change. The counselor may believe that clients who are ambivalent need someone to gently nudge them off the proverbial fence. Or this desire to take a directive approach to ambivalence may be based on the counselor’s own personal history with ambivalence. The counselor may have learned that ambivalence can be an uncomfortable state of being; therefore, the counselor may wish to reduce the client’s distress quickly by telling the client how to relieve that discomfort. This desire to want to fix a client’s problems is referred to by Miller and Rollnick (2013) as the righting reflex and can be manifested by the counselor trying to persuade clients that their problem must be addressed, telling clients how they should go about changing, trying to convince clients of the benefits of change, offering unsolicited information, and emphasizing the consequences of the status quo (Rosengren, 2018). Although well-intentioned, this directive style to counseling ambivalent clients produces counterintuitive effects. The problem with taking a directive stance with ambivalent clients is that when a counselor advises, educates, or persuades a client to change, the more likely it is that the client will respond with the arguments against

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change. Think of it this way, clients who are ambivalent already know both sides of the change argument. When counselors take the side in support of change, clients are left to articulate the arguments against change. A verbal signal that this interaction is happening is when a client responds with, “yes, but”; the client acknowledges the counselor’s comments supporting change and then immediately responds with a “but” followed by a statement against change. Taking this directive approach externalizes the client’s ambivalence, but not in a good way because the client is arguing the side against change (Miller & Rollnick, 2013). This decreases the likelihood of change because it strengthens, rather than helps to resolve, the client’s ambivalence. Interestingly, Westra (2012) pointed out that a counselor’s use of the righting reflex could result in increased client compliance in counseling, but that compliance might not translate to actual increased motivation to change or long-term treatment success. For example, clients may dutifully fill out a self-monitoring log between sessions just to satisfy their counselor, rather than to learn how they can increase engagement in meaningful life activities. Two theories of human behavior inform our understanding of why the righting reflex is problematic with people who are ambivalent about change. According to Self-Determination Theory (Ryan & Deci, 2017), three fundamental needs must be supported for an individual to have autonomous, or self-regulated, motivation toward a behavior. These are (a) autonomy (i.e., the behavior is self-endorsed and that it is congruent with the person’s interests and values), (b) competence (i.e., feelings of mastery or perceived ability), and (c) relatedness (i.e., the need to feel cared for by others; Ryan & Deci, 2017). People are more likely to be intrinsically motivated to engage in a behavior when these needs are satisfied. Unsurprisingly, a counselor’s use of the righting reflex can interfere with establishing an environment that is supportive of client autonomy, competence, and relatedness. When a counselor argues for change, clients will probably be less likely to perceive that their decision and action to change are the result of an autonomous decision. Further, clients may feel that they lack the skills to change when they are told how to change by their counselor. Clients also may feel less heard or valued if the counselor prioritizes advice-giving and persuasion over providing support and accurate empathy. Numerous studies of client and therapist behaviors support the claim that the righting reflex can heighten discord and decrease the odds of client change. In an early study of MI, Miller et al. (1993) observed an increase in client resistance to change when the therapists used a directive-confrontation style when delivering personalize feedback on the client’s alcohol consumption. Further, the more that the therapist confronted, the more the client drank one year following the intervention (Miller et al., 1993). Examining adolescent patient-provided communication about diabetes, Caccavale et al. (2019) found that poorer diabetes behavior adherence and glycemic control were associated with provider

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use of confrontation and persuasion during medical encounters. Several studies of substance use disorder treatment indicate that the use of a directive style is especially unhelpful with clients who are resistant to change (Karno & Longabaugh, 2005; Karno et al., 2012). In one study, increased therapist structure (i.e., the therapist providing instruction to the client, introducing new agenda items, or changing topics in session) predicted fewer days abstinent and more heavy-drinking days in the year after treatment for clients with higher levels of interpersonal reactance (Karno et al., 2009). In addition to evoking language in support of the status quo, the righting reflex also is problematic because it does not provide a space for clients to articulate and elaborate upon their own beliefs in support of change. In describing Self-Perception Theory, Bem (1967) posited that people are more convinced by their own arguments, rather than by arguments they hear from others. Thus, one can speculate that when clients voice and defend their own arguments for change they become more committed to act upon them (Hettema et al., 2005). Counselors who instruct, advise, and persuade miss opportunities for clients to convince themselves of the need to change. Considerable evidence, including from meta-analytic research of MI in the treatment of addictive behaviors, show that increased in session client language in support of change predicts positive treatment outcomes (Magill et al., 2019; Martin et al., 2011). These findings suggest that a guiding style, one in which the counselor carefully listens and selectively responds to client language for and against change, may be more beneficial in facilitating change and positive treatment outcomes. Given the problems with applying a directive style with ambivalent clients, an important tenet of MI is for counselors to resist the righting reflex (Miller & Rollnick, 2013). Rather than attempting to fix the client’s problems, counselors engage in a style of communication that evokes and strengthens the client’s own arguments for change. Rooted in the four key elements of MI Spirit: partnership, acceptance, compassion, and evocation, the counselor’s strategic responding to client language helps create the conditions of autonomy, competence, and relatedness within the therapeutic milieu that, according to Self-Determination Theory (Ryan & Deci, 2017), support autonomous behavior change. Relatedly, it also provides a platform for clients to form or clarify attitudes about change that are based on their own arguments, a key principle of Self-Perception Theory (Bem, 1967), which in turn makes it more likely for them to commit to action. By resisting the righting reflex, counselors help clients strengthen their own motivation and resolve to change. Why Resolving Ambivalence Is Central in Motivational Interviewing Counselors who use MI structure the conversation so that clients talk themselves into changing (Miller & Rollnick, 2013). They selectively

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respond to client language that is in favor of change. Evoking and strengthening pro-change language, or change talk, allows clients to hear back and elaborate on their best arguments for change. These arguments might reflect a client’s reasons, perceived capacity, or need to change; arguments also might represent values and strengths that increase the client’s self-efficacy and hope in change. This process helps tip the balance in favor of change. Once the scales shift toward change, conflict between the opposing beliefs about change is resolved and momentum builds within the client to act. Without applying this strategic and skillful approach, ambivalent clients will remain stuck, alternating between arguments that are for and against changing. Consider the metaphor of riding on a merry-go-round to understand the process of counseling an ambivalent client. When the counselor takes a non-directive approach, not selectively responding to change talk, the client and counselor go around in circles. They pass by arguments for and against change, never settling on place to disembark from the ride. When the counselor purposefully responds to change talk, the client becomes more aware of these arguments and begins envisioning what change will look like. Over time, the sustain talk fades into the background. During this process, the client increases in awareness of how to step off the carousel and determination to begin taking steps toward change. Studies have shown that spending an equal amount of time on both sides of ambivalence, such as using a decisional balance (Janis & Mann, 1977), further heightens the person’s ambivalence and decreases commitment to change (Miller & Rose, 2015). Magill et al. (2013) found that therapist focus on ambivalence predicted greater alcohol use among clients in outpatient treatment for alcohol use disorder; whereas, efforts to elicit and strengthen commitment to change predicted greater rates of abstinence. The emphasis on evoking change talk in MI does not mean that arguments against change should always be disregarded. Wagner and Ingersoll (2013) offered several situations when counselors should attend to client sustain talk. Exploring the advantages of the status quo helps establish trust and strengthen the alliance with ambivalent clients (Wagner & Ingersoll, 2013). This groundwork pays off when the counselor begins evoking change talk. Without a strong therapeutic relationship, the likelihood that the client will engage in a frank and honest conversation about change is low. Sustain talk also offers clues about the contingencies within the client’s environment that maintain the status quo as well as possible barriers to change. Understanding these obstacles can enhance the counselor’s efforts at evoking salient change talk and planning for change. In each case when sustain talk is explored, the underlying intention is that doing so will make the counselor more effective at strengthening change talk. Moreover, the balance of time in MI should be squarely focused on evoking and exploring change talk. Understanding the different types of change talk, and what these statements suggest about the client’s ambivalence to change, is critical for MI counselors to learn.

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The Language of Motivational Interviewing: Change Talk According to Rosengren (2018), three elements must be present for a statement to be change talk. First, the statement must reflect some change of the status quo. Second, the statement must pertain to a specific goal or change target. Though, more general statements about change (e.g., wanting to feel less depressed) can signal some momentum toward making a specific change (e.g., improving interpersonal relationships and increasing physical health behaviors) and represent potential “seeds” that can grow into change talk if they are appropriately nurtured by the counselor (Rosengren, 2018). Third, change talk must be phrased in the present tense. A statement such as “when I was younger, I was able to manage my manic episodes” may not indicate confidence in coping with symptoms of mania in the present. Similarly, statements about the client’s future need or desire to change might be better understood as sustain talk, in that they support maintaining the current status quo. Once change talk is identified, there is value in considering to what extent these statements indicate movement toward change. Change talk can be understood as comprising two categories, preparatory and mobilizing statements (see Table 3.1). Preparatory language reflects the prochange side of ambivalence, whereas mobilizing language suggests that the client’s ambivalence has been resolved and that change is imminent (Miller & Rollnick, 2013). In arguing for the usefulness of distinguishing between these two kinds of language, Miller and Rollnick (2013) use the metaphor of an ambivalence hill. Evoking and strengthening preparatory change talk is like climbing uphill. This process requires considerable effort and caution, carefully tending to sustain talk when it arises, as these statements against change can cause slips and unstable footing. Once reaching the top of the hill, descending requires less exertion because momentum is on your side. This is what it is like when attending Table 3.1 Examples of Change Talk from Evoking a Client’s Motivation to Engage in Treatment Change talk

Example

Desire

“I would like to do something about how much I worry about things” “I know that I can do this” “In the long run, I will feel better about myself” “Things must change now” “I promise to do this week’s homework” “I’m prepared to use the new coping strategies we have practiced” “I spoke to my wife about what we discussed last week”

Ability Reasons Need Commitment Activation Taking Steps

Note: Desire, Ability, Reasons, and Need = Preparatory Change Talk; Commitment, Activation, and Taking Steps = Mobilizing Change Talk.

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to mobilizing change talk. Ambivalence is resolved and the focus centers on intention and action. This part of the journey is not without its own hazards; traveling downhill too fast can increase anxiety and result in stumbles. Knowing whether change talk is preparatory or mobilizing helps the clinician determine the extent to which the client’s ambivalence has been resolved and when to transition into the planning phase. There are four types of preparatory change talk: Desire, Ability, Reasons, and Need (DARN; Miller & Rollnick, 2013). Each component points toward the possibility of change but stops short of signifying that change is about to happen. Desire language indicates that the client wants to change, yet these statements are not as strong as expressions of intention to change. Ability language represents one’s sense of self-efficacy or perceived capacity to enact change. In some cases, ability statements are phrased in hypothetical language (e.g., “I might be able to . . .”; Miller & Rollnick). Reasons include statements of the potential advantages of changing and the disadvantages of maintaining the status quo. Miller and Rollnick (2013) describe these statements as possessing an “if . . . then” structure (p. 161); for example, “If I meditated more often, then I would feel less stress.” Finally, verbal expressions of the urgency of change are examples of Need change talk. Change might be needed immediately because of self-perceived problems associated with the status quo (Rosengren, 2018). Mobilizing change talk has three components: Commitment, Activation, and Taking Steps (CATS; Miller & Rollnick, 2013). Commitment statements include action words that convey an intention to change (Rosengren, 2018). These statements can vary in their intensity, but generally point toward a resolution of ambivalence and that a decision has been made to act. According to Miller and Rollnick (2013), these statements are among the most important types of change talk because being motivated to change is insufficient without having a commitment to action. Research on change talk utterances during MI sessions validate the importance of commitment language. In a study of MI on drug use outcomes, Amrhein et al. (2003) found that commitment language strength was a better predictor of proportion of days abstinent from substance use than preparatory change talk (i.e., DARN). Activation language differs from Commitment change talk in that rather than representing a promise or declaration of change these statements reflect an openness or willingness to take steps toward change. This type of mobilizing change talk often arises when the client begins to envision what changing would look like or starts planning for change. Further, Activation change talk often is the bridge between commitment, or making a promise to act, and starting to implement a change plan, or Taking Steps. Statements about actions made in support of change are examples of Taking Steps change talk. It is critical that these steps, however small or tentative, be acknowledged and encouraged by the counselor to help strengthen the client’s perceived confidence in making the change.

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A fundamental skill of MI-adherent practice is identifying change talk and sustain talk. These statements provide the counselor with clues about the client’s readiness to change. Using these clues, the clinician can adjust the pace and focus of counseling. If a client verbalizes a strong commitment to change, transitioning into the action phase of treatment is warranted; however, the clinician may wish to focus on engaging and revisiting goal setting if the client expresses sustain talk. Importantly, DARN CATS can be used to categorize these statements as well. When exploring both sides of change, clients may express their preference for the status quo (Desire), confidence in keeping things the way they are now (Ability), thoughts on why change would be too difficult (Reasons), or why they must accept their current situation (Need). Examples of mobilizing sustain talk, or language that reflects a resolution of ambivalence in the direction of the status quo, can include statements of one’s determination to not change (Commitment), disinterest in planning to change (Activation), or recent engagement in the problem behavior (Taking Steps). Convincing evidence exists that client language in session is an important predictor of counseling outcomes (Magill et al., 2018; Magill et al., 2019). Borsari et al. (2018) found that increased change talk in session was associated with significant reductions in alcohol use and alcoholrelated problems with college students who were mandated to counseling. In an earlier study of undergraduates mandated to alcohol counseling, Apodaca et al. (2014) found that sustain talk predicted poorer treatment outcomes, including more heavy drinking day and alcohol problems at the three-month follow-up. Studies of MI-counselor skills and client language in session provide evidence that supports the technical hypothesis of MI; counselor MI-consistent behavior is associated with increased client change talk and decreased sustain talk which in turn predicts positive treatment outcomes (Vader et al., 2010). These findings point to the central task of eliciting change talk in MI. How to Elicit Change Talk There are several techniques that counselors can use to evoke client change talk. Perhaps the most direct approach is the use of open-ended questions that elicit specific categories of change talk. With ambivalent clients, these questions should be limited to evoking preparatory change talk (DARN), because trying to elicit mobilizing change talk before a client’s ambivalence has been resolved typically results in increased sustain talk. For example, asking clients what steps they can take to change, before they have decided to act, will likely evoke some hypothetical strategies followed by a “but” and an enumeration of possible problems with enacting change now. Asking questions, such as “what do you hope to get out of counseling?” (desire), “if you decide to change, how can you do it?” (ability), “what are some important reasons to change?” (reasons),

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and “why is it necessary to change, now?” (need) can evoke preparatory change talk. Another way to elicit change talk is to explore extreme outcomes related to change and maintaining the status quo (Miller & Rollnick, 2013). Asking questions about the worst thing that could happen if they do not change, or the best possible outcome of change, can help draw out reasons to change and increase the client’s sense of urgency. Querying extremes also helps identify the client’s most important reasons to change. Knowing what is important to the client allows the counselor to concentrate on exploring this change talk in greater depth. This kind of prioritization is an important consideration, especially in short-term mental health settings, because not all change talk will have equal value or meaning to the client; as a result, it is necessary to identify and focus on what is most important. When used skillfully, scaling questions that assess perceived importance and confidence to change can evoke change talk. Typically, these questions use a scale of 0–10, with zero indicating no importance or confidence at all, and 10 representing extreme importance or confidence to change. Assessing importance (i.e., On a scale of 0–10, how important is it for you to make this change now?) can lead to desire, reasons, need, and commitment change talk; exploring confidence (On a scale of 0–10, how confident are you that you can make this change now?) is a useful way to draw out ability change talk. Scaling questions on their own does not bring about change talk; instead, the questions that follow the client’s ratings of importance or confidence are what evokes arguments for change. If a client’s importance rating is a 5 and the counselor asks, “why are you at a 5 and not a 7?” the client will respond with sustain talk, such as reasons why change is not such an urgent matter. But if the counselor asks why a lower rating of importance was not selected (“why are you a 5 and not a 2?”), the client will respond with change talk. It also helps to ask what it would take for the client’s confidence or importance rating to increase to a higher number. Those responses can provide openings for the counselor to offer information or resources that strengthen the client’s desire or perceived capacity to change. Another powerful strategy to evoke change talk is to ask clients to look back or ahead in their life (Miller & Rollnick, 2013). Looking back might entail asking the client to describe a time before the problem developed (what were things like before your fear of leaving home became so severe?) and to compare what that time was like to the present. Contrasting these two times can evoke reasons to change and increase urgency to make improvements that bring the client closer to how things were during that earlier time. Looking ahead involves having the client reflect on how things will differ once change occurs (how would things be different in the future if you made this change?). Like exploring the best possible

46 Foundations of Motivational Interviewing outcome of change, looking ahead encourages clients to reflect upon the important and long-term benefits of change. Envisioning a better future also helps increase the client’s resolve to change. In addition to looking back and ahead, there are several other ways to evoke change talk by developing discrepancies between the client’s self-perceptions and current circumstances. These strategies are especially helpful when direct efforts to elicit change talk are unfruitful. One method of drawing out potential change talk is to explore how clients’ present behaviors conflict with their personal values or goals. Recognizing inconsistencies between values and current behaviors, can be an important catalyst for clients to commit and take steps to change. It is crucial to stress here that efforts to develop discrepancies should not be aimed at increasing clients’ shame or guilt, but rather the focus should be on helping clients envision how they will feel different by engaging in values-oriented actions. A more in-depth discussion of developing discrepancies is discussed in Chapter 1. A deck of cards containing 83 different personal values developed by Miller et al. (2001) can be used to structure these conversations. Clients select their top 10–15 values to sort into one of three piles: (1) values negatively impacted by their current problem, (2) values positively impacted by their current problem, or (3) values not impacted by their current problem. Sorting cards into these piles can help explore discrepancies and identify key arguments for change. One way of doing this is to point out conflicting values using double-sided reflections that acknowledge both sides of change (e.g., “drinking positively impacts your value of having fun and it also has created some significant problems for your values of health, family, and safety”). Using open questions and reflections, counselors can encourage client exploration and elaboration of the values that have been negatively impacted by the problem to draw out and strengthen change talk. Another method of developing discrepancies is to offer clients personalized feedback on their assessment results. Assessment results collected in counseling can be presented alongside aggregated scores from a comparison group of similar individuals. This juxtaposition allows clients to consider how their behavior or current level of functioning is similar or dissimilar to others. For example, providing clients with their percentile rankings on a standardized assessment of clinical symptoms (e.g., Symptom Checklist-90-Revised; Derogatis, 1994) to show how their current experience of psychological problems differs from other individuals who are in counseling, can potentially increase their urgency and desire to engage in treatment. Although there is considerable evidence that normative feedback can result in positive outcomes, such as in the prevention and treatment of alcohol misuse (Cadigan et al., 2015), this approach is not effective with all clients. Clients lacking interpersonal relationships or who view

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themselves as “loners” are less likely to want to change so that their behaviors more closely adhere to group norms. Also, some evidence exists that providing normative feedback to adolescents in substance use treatment can increase sustain talk (Osilla et al., 2015) and that adolescents who receive normative feedback and voice high levels of sustain talk in session actually increase their substance use over time (Davis et al., 2016). For some, normative feedback may strengthen their resolve to maintain the status quo or continue problematic behaviors because these ways of being help them stand out from the crowd. As a result, clinicians should use caution in utilizing normative feedback with their clients, particularly with those who are detached from interpersonal relationships or have significant deficits in social communication. Another approach to personalized feedback is to provide information that places client assessment results into some context. Comparing a client’s reported functioning to diagnostic criteria listed in the DSM 5 (American Psychiatric Association, 2013), or self-reported use of alcohol to the Centers for Disease Control and Prevention’s (2020) dietary guidelines on moderate drinking, are two examples of how to evoke arguments for change by providing information that sheds new light on a client’s behaviors or functioning. Having a new perspective on their behavior or current level of functioning also can help propel clients into action. For example, seeing the similarities between specific diagnostic criteria and one’s current symptoms can strengthen commitment to engage in treatment to treat a condition that has now has a name. How to Respond to Change Talk When change talk emerges in session, it is important that the counselor guides the client in a process of fully exploring these pro-change arguments. This is because it is not uncommon for clients to offer change talk that is no more than just wishful thinking, or what they believe the counselor wants to hear (Miller & Rollnick, 2013); therefore, skillfully responding to change talk to encourage elaboration helps the counselor determine whether these statements are meaningful to the client. Encouraging elaboration also can increase the intensity of the change talk, thereby strengthening the client’s motivation to change. Without this indepth exploration, MI is less likely to be effective at catalyzing client change. In a meta-analysis of 13 separate studies of MI in the treatment of addictive behaviors, Magill et al. (2019) found that increased occurrences of client change talk in session was not related to treatment outcomes. These authors speculated that it is possible that strength and sincerity of change talk hold greater validity than frequency of change talk in predicting behavior change. This makes sense as it is unlikely that all change talk statements uttered in session hold equal significance to the client. Thorough exploration of change talk enables counselors to identify and bring

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to the forefront their clients’ most important arguments for change. Miller and Arkowitz (2015) offer a useful acronym, very similar to OARS, to remember when responding to change talk: Elaboration, Affirm, Reflect, and Summarize (EARS). When change talk emerges, respond with questions that encourage Elaboration. This includes asking for specific examples of change talk shared by the client. Asking for elaboration can be a simple invitation to the client to continue talking about change talk when it surfaces, such as “tell me some more about that.” Encouraging elaboration can help animate and give more substance to change talk. Also, it can help shed light on other arguments for change that are important to the client. For example, if “feeling better” is a reason to change articulated by a client, asking for examples of what “feeling better” looks like in the client’s life, may reveal more reasons to change. Bringing to mind these specific and concrete examples can help tip the balance of the client’s ambivalence toward change. Specific to ability change talk, inquiring about and exploring past successes related to the behavior change being discussed can be a helpful way to increase the client’s self-efficacy and determination to change (Wagner & Ingersoll, 2013). Encouraging elaboration also can provide information on possible change strategies and ways to overcome barriers to change that can be useful to revisit in the planning process of MI. To Affirm change talk is to respond with gratitude and encouragement to the client (Miller & Arkowitz, 2015). This is important for several reasons. According to Self-Determination Theory, competence and relatedness represent two of the three needs that must be met for individuals to engage in self-regulated behavior (Ryan & Deci, 2017). Statements that reflect a kind of “prizing” of the client by the counselor can go a long way establishing a therapeutic environment that fulfills the need for relatedness. Further, affirming the client’s efforts to change can help satisfy the need for competence. It is not uncommon for clients to minimize the small, yet positive steps taken to facilitate change during counseling. Even clients who are deeply ambivalent about change, the fact that they are in counseling and speaking openly about their ambivalence are actions that move them in the direction of change. Affirmations can acknowledge these efforts as evidence that the client does possess the capacity to change (e.g., “You have taken the first steps to change”). When counselors Reflect change talk, they encourage clients to continue exploring it. When the counselor reflects change talk, it is very likely that the client will respond by talking more about change. Simple reflections, or reflections that paraphrase and do not add anything new to client content, keep the focus of the conversation on change talk. This process furthers elaboration of the change talk already offered by the client and can help the client identify and parse through new prochange arguments. Complex reflections, or reflections that offer a new

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perspective to client content, enable the counselor to suggest new arguments for change. These reflections can represent guesses by the counselor about why change is important, for example, which are based on what the client has said so far. Counselors also can use complex reflections to link change talk to client values or strengths. Situating expressed desire, reasons, and need to change within the context of a client’s deeply held values can strengthen that existing change talk and perhaps spur the client into action. Commitment and motivation to change also can be strengthened using complex reflections that connect change talk with the client’s affective state in session (e.g., “You light up and seem giddy when talking about the best possible outcome of changing”). To Summarize change talk is to respond with a collection of the client’s best arguments for change. Clients voice many different types of change talk in session. Summaries are not exhaustive lists of these statements. Instead, summaries include the change talk that is most salient to the client. It is helpful to conclude the summary with a question that invites the client to offer any change talk that was missing from the summary (e.g., “have I missed anything?”). Research on the significance of mobilizing change talk in predicting behavior change in treatment is worth considering when constructing summaries. Specifically, if a client verbalizes even a tepid commitment to change, consider highlighting it in the summary. Once the client’s most important DARN CATS statements are summarized (Rosengren, 2018), this provides an opportunity for the counselor to ask a question that encourages reflection on possible actions moving forward (e.g., “Given everything we have discussed, what do you think you will do?”). This type of question helps increase the client’s momentum to change by eliciting mobilizing change talk. Let’s explore how these strategies might work in a clinical setting. In the following case study, the clinician uses MI strategies to evoke and strengthen client change talk related to treatment adherence.

Case Study Vanessa is a 35-year-old African American woman restarting treatment for depression in an outpatient CMH program. Prior to being added to the counselor’s caseload, Vanessa had been waitlisted for treatment services after missing three sessions with her previous counselor. Vanessa lives with her two children and mother and is currently on medical disability due to injuries suffered in a car accident. She is in counseling for help with her symptoms of depression, which include difficulty concentrating, depressed mood, low energy, indecisiveness, and feelings of worthlessness. Vanessa has now seen the counselor five times; however, she did not attend her last scheduled session. This was the second time that she has missed a session without calling to reschedule. In this

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exchange, change talk related to regular session attendance is elicited and reinforced by the counselor. COUNSELOR:

Vanessa, I would like to check in with you about session attendance. VANESSA: Okay. COUNSELOR: You did not attend our session last week. This is the second time that you missed a scheduled appointment. If this happens again, our policy requires that you be placed back on the waitlist until another counselor is available to work with you. [provided information] VANESSA: I understand. I wanted to meet, really, but I was so overwhelmed. That morning, I got a call from my daughter’s father that made me feel completely out of it for the rest of the day. COUNSELOR: Things were really chaotic for you, yet you still really wanted to come in for our session that day. [reflection] VANESSA: Yes. I know that we have not meet that many times, but I like speaking with you. I feel like I am getting a lot out of these sessions. COUNSELOR: I enjoy speaking with you too! You have been really open and engaged during our past sessions. [affirmation] VANESSA: I feel like this is the only place that I have for me. COUNSELOR: Tell me some more about that. [encourage elaboration] VANESSA: I am usually too busy thinking about my kids or mother to worry about myself. But when I am here, it is all about me. I want to get my life back together. COUNSELOR: This is one way for you to get your life back on track. [reflection] VANESSA: Yes. COUNSELOR: How has it helped you recently? [open-ended question] After checking in with Vanessa about the clinic’s session attendance policy, the counselor focused the conversation on eliciting and strengthening change talk. But the counselor does not completely ignore the obstacles that have contributed to Vanessa missing her appointments. The counselor uses a double-sided reflection (Miller & Rollnick, 2013) to acknowledge both sides of Vanessa’s change dilemma: that last week she had been so overwhelmed that she was unable make her appointment (sustain talk) and that counseling has had a positive effect on her life (change talk). Concluding this reflection with change talk invited Vanessa to continue discussing this reason for her to participate in treatment. The counselor also used an affirmation, recognizing Vanessa’s efforts to engage in their sessions together. Once a potential key argument for continued counseling attendance emerged (i.e., counseling provides a venue for Vanessa to focus on herself), the counselor encourages elaboration and exploration by asking for examples. In the following exchange, the counselor explores Vanessa’s confidence and ability to attend future scheduled sessions.

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COUNSELOR:

Vanessa, so far you have mentioned several ways that you have benefited from counseling. Counseling is a venue for you to focus on yourself. We have used some of our time together to plan for the future. That includes discussing your goal of returning to work. Our sessions also have helped you navigate some of the stressful situations in your life that are happening right now. While, at times, you might think that that you do not have the time for counseling, or to take care of yourself in general, you also recognize that our sessions help you respond better and more effectively to the major stressors in your life. [summary] VANESSA: Yes. I am just worried that something is going to come up in the future that will cause me to miss another session. COUNSELOR: On a scale of 0–10, with 0 being no confidence at all and 10 indicating great confidence, how confident are you that you will be able to attend future weekly sessions? [scaling question] VANESSA: I guess that I am a 5. COUNSELOR: Why a 5 and not a 2? [open-ended question] VANESSA: Well, it’s because last week was a little unusual. With that call from my daughter’s father, things were more stressful than usual. And before missing last week’s appointment, I had been better at coming to session, even on days when I have been really overwhelmed with stress. COUNSELOR: Despite at times feeling pretty stressed, you have shown your determination and resilience by making it in for our sessions. [affirmation through reflection] VANESSA: It hasn’t been easy. But I try hard to make these appointments. COUNSELOR: In the past, how were you able to make it into counseling when you were overwhelmed and stressed out? [open-ended question] VANESSA: Last month, I was really overwhelmed. I was in a lot of physical pain and I was totally stressed out because my kids were getting in trouble in school. COUNSELOR: And you made your counseling appointment. [reflection] VANESSA: I was thinking that coming in for counseling was not a priority. But then I realized that it might be good to talk with you about everything that was going on. COUNSELOR: You stopped to think about how coming in for counseling could help you manage all of your stress. [reflection] VANESSA: Yes. COUNSELOR How can you apply this lesson in the future? [open-ended question] The counselor begins with a summary of the key pro-change arguments for attending counseling. Vanessa’s response suggests that she is unsure that she has the ability to attend future sessions; therefore, the counselor asks a scaling question to assess her confidence. Inquiring about why Vanessa did not select a lower number helps evoke ability change talk. The

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counselor carefully reflects this change talk, highlighting Vanessa’s values and strengths (i.e., her determination and resilience). The exchange continues with the counselor exploring past successes and how she can apply these experiences in the future. Perhaps following another summary of change talk, this time of ability and mobilizing change talk, the counselor can use a key question to transition into planning. This plan could include strategies that Vanessa can use in the future when potential barriers to treatment participation arise.

Summary People who are ambivalent already are aware of both sides of change. Trying to instill or offer arguments for change fails to acknowledge this reality and can lead to increased client ambivalence and greater discord within the therapeutic relationship. Similarly, listening carefully to the client and offering no direction at all communicates acceptance but rarely leads to resolution of the client’s ambivalence. Instead, MI clinicians listen with curiosity and purpose to the client’s story, carefully teasing out and encouraging elaboration of the client’s best arguments for change. Selectively eliciting and reinforcing client change talk help strengthen the client’s motivation and commitment to enact change Activities and Resources 1. Write as many open-ended questions as you can to elicit each of the DARN CATS. 2. Re-read the case study, but this time look for examples of change and sustain talk in her statements. Develop a list of responses (using OARS) of other ways that the counselor could have elicited or strengthened her change talk. 3. Review the Personal Values Card Sort found at www.motivationalinterviewing.org/sites/default/files/valuescardsort_0.pdf. Select your top ten values. Then place each value into one of three piles: (1) MI is consistent with this value, (2) MI is inconsistent with this value, (3) MI is not related to this value. Discuss with a partner how using MI fits with your personal values. Explore ways in which this activity can develop discrepancies and evoke change talk.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. https://doi.org/ 10.1176/appi.books.9780890425596 Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client commitment language during motivational interviewing predicts drug

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use outcomes. Journal of Consulting and Clinical Psychology, 71(5), 862–878. https://doi.org/10.1037/0022-006X.71.5.862 Apodaca, T. R., Borsari, B., Jackson, K. M., Magill, M., Longabaugh, R., Mastroleo, N. R., & Barnett, N. P. (2014). Sustain talk predicts poorer outcomes among mandated college student drinkers receiving a brief motivational intervention. Psychology of Addictive Behaviors, 28(3), 631–638. https://doi.org/10.1037/ a0037296 Bem, D. J. (1967). Self-perception: An alternative interpretation of cognitive dissonance phenomena. Psychological Review, 74, 183–200. Borsari, B., Yalch, M. M., Pedrelli, P., Radomski, S., Bachrach, R. L., & Read, J. P. (2018). Associations among trauma, depression, and alcohol use profiles and treatment motivation and engagement in college students. Journal of American College Health, 66(7), 644–654. https://doi.org/10.1080/07448481.2018.1446438 Caccavale, L. J., Corona, R., LaRose, J. G., Mazzeo, S. E., Sova, A. R., & Bean, M. K. (2019). Exploring the role of motivational interviewing in adolescent patient-provider communication about type 1 diabetes. Pediatric Diabetes, 20(2), 217–225. https://doi.org/10.1111/pedi.12810 Cadigan, J. M., Martens, M. P., & Herman, K. C. (2015). A latent profile analysis of drinking motives among heavy drinking college students. Addictive Behaviors, 51, 100–105. https://doi.org/10.1016/j.addbeh.2015.07.029 Centers for Disease Control and Prevention. (2020, December 29). Dietary guidelines for alcohol. Retrieved from www.cdc.gov/alcohol/fact-sheets/moderatedrinking.htm Davis, J. P., Houck, J. M., Rowell, L. N., Benson, J. G., & Smith, D. C. (2016). Brief motivational interviewing and normative feedback for adolescents: change language and alcohol use outcomes. Journal of Substance Abuse Treatment, 65, 66–73. https://doi.org/10.1016/j.jsat.2015.10.004 Derogatis, L. R. (1994). SCL-90-R: Symptom checklist-90-R: Administration, scoring & procedures manual. Pearson. Engle, D. E., & Arkowitz, H. (2006). Ambivalence in psychotherapy: Facilitating readiness to change. Guilford Press. Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91–111. https://doi.org/10.1146/annurev. clinpsy.1.102803.143833 Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. Free Press. Karno, M. P., Farabee, D., Brecht, M.-L., & Rawson, R. (2012). Patient reactance moderates the effect of directive telephone counseling for methamphetamine users. Journal of Studies on Alcohol and Drugs, 73(5), 844–850. https://doi. org/10.15288/jsad.2012.73.844 Karno, M. P., & Longabaugh, R. (2005). Less directiveness by therapists improves drinking outcomes of reactant clients in alcoholism treatment. Journal of Consulting and Clinical Psychology, 73(2), 262–267. https://doi.org/10.1037/0022006X.73.2.262 Karno, M. P., Longabaugh, R., & Herbeck, D. (2009). Patient reactance as a moderator of the effect of therapist structure on posttreatment alcohol use. Journal of Studies on Alcohol and Drugs, 70(6), 929–936. https://doi.org/10.15288/ jsad.2009.70.929

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Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., Tonigan, J. S., & Moyers, T. (2018). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of Consulting and Clinical Psychology, 86(2), 140–157. https://doi. org/10.1037/ccp0000250 Magill, M., Bernstein, M. H., Hoadley, A., Borsari, B., Apodaca, T. R., Gaume, J., & Tonigan, J. S. (2019). Do what you say and say what you are going to do: A preliminary meta-analysis of client change and sustain talk subtypes in motivational interviewing. Psychotherapy Research, 29(7), 860–869. https://doi.org/ 10.1080/10503307.2018.1490973 Magill, M., Stout, R. L., & Apodaca, T. R. (2013). Therapist focus on ambivalence and commitment: A longitudinal analysis of Motivational Interviewing treatment ingredients. Psychology of Addictive Behaviors, 27(3), 754–762. https://doi.org/10.1037/a0029639 Martin, T., Christopher, P. J., Houck, J. M., & Moyers, T. B. (2011). The structure of client language and drinking outcomes in project match. Psychology of Addictive Behaviors, 25(3), 439–445. https://doi.org/10.1037/a0023129 Mazzucchelli, T., Kane, R., & Rees, C. (2009). Behavioral activation treatments for depression in adults: A meta-analysis and review. Clinical Psychology: Science and Practice, 16(4), 383–411. https://doi.org/10.1111/j.1468-2850.2009.01178.x Miller, W. R., & Arkowitz, H. (2015). Learning, applying, and extending motivational interviewing. In H. Arkowitz, W. R. Miller, S. Rollnick, A. Aviram, & I. C. Balán (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford Press. Miller, W. R., Baca, J. C., Matthews, D. B., & Wilbourne, P. L. (2001). Personal values card sort. In W. R. Miller & J. C’de Baca (Eds.), Quantum change: When epiphanies and sudden insights transform ordinary lives. Guilford Press. https:// motivationalinterviewing.org/sites/default/files/valuescardsort_0.pdf Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61(3), 455–461. https://doi. org/10.1037/0022-006X.61.3.455 Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527–537. https://doi.org/10.1037/a0016830 Miller, W. R., & Rose, G. S. (2015). Motivational interviewing and decisional balance: Contrasting responses to client ambivalence. Behavioural and Cognitive Psychotherapy, 43(2), 129–141. https://doi.org/10.1017/S1352465813000878 Naar, S., & Safren, S. A. (2017). Motivational interviewing and CBT: Combining strategies for maximum effectiveness. Guilford Press. Osilla, K. C., Ortiz, J. A., Miles, J. N. V., Pedersen, E. R., Houck, J. M., & D’Amico, E. J. (2015). How group factors affect adolescent change talk and substance use outcomes: Implications for motivational interviewing training. Journal of Counseling Psychology, 62(1), 79–86. https://doi.org/10.1037/cou0000049 Rosengren, D. B. (2018). Building motivational interviewing skills: A practitioner workbook (2nd ed.). Guilford Press. Ryan, R. M., & Deci, E. L. (2017). Self-determination theory: Basic psychological needs in motivation, development, and wellness. Guilford Press.

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Vader, A. M., Walters, S. T., Prabhu, G. C., Houck, J. M., & Field, C. A. (2010). The language of motivational interviewing and feedback: Counselor language, client language, and client drinking outcomes. Psychology of Addictive Behaviors, 24(2), 190–197. https://doi.org/10.1037/a0018749 Wagner, C. C., & Ingersoll, K. S. (2013). Motivational interviewing in groups. Guilford Press. Westra, H. A. (2012). Motivational interviewing in the treatment of anxiety. Guilford Press. Zuckoff, A., Balán, I. C., & Simpson, H. B. (2015). Enhancing the effectiveness of exposure and response prevention in the treatment of obsessive-compulsive disorder: Exploring a role for motivational interviewing. In H. Arkowitz, W. R. Miller, S. Rollnick, A. Aviram, & I. C. Balán (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford Press.

4

Motivational Interviewing in Action The Four Processes

Introduction In previous chapters, we discussed MI spirit (Chapter 1), the core clinical skills used in MI (Chapter 2), and how these core skills are used to evoke and strengthen client change talk (Chapter 3). Consider the spirit and core skills as the essential ingredients of MI. Miller and Rollnick (2013) proposed four processes: engaging, focusing, evoking, and planning as the recipe for using these ingredients. The processes offer guidance on how to apply the core MI skills based on the client’s engagement in counseling and motivation to change. In this chapter, we will describe what MI looks like in practice by discussing the key goals and skills associated with each of the four processes.

What Motivational Interviewing Looks Like in Practice Before the introduction of the four processes in Miller and Rollnick’s (2013), the third edition of Motivational Interviewing: Helping people change, little guidance existed on how to practice MI. Guidelines that were available on how to implement MI skills and principles failed to capture the many complexities associated with discussing change (Miller & Rollnick, 2013). This holds true to our experiences practicing MI before the four processes were introduced. There were times when we struggled to understand why our efforts to evoke and strengthen client change were unsuccessful in strengthening commitment to change. Looking back, it is clear to us that in those cases it was likely that we did not sufficiently address certain prerequisites of evoking, such as establishing a strong therapeutic relationship and agreeing on change goals, which are necessary to evoke meaningful and relevant client change talk. The four processes are a sequence in which MI plays out. More specifically, this framework outlines the key process issues associated with the MI interaction, from beginning to end. During the first process, engagement, the clinician establishes a strong therapeutic relationship with the client. While building rapport, the DOI: 10.4324/9781351244596-5

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clinician also explores both sides of the client’s change dilemma. This includes learning the client’s arguments for and against change. As a clearer picture emerges of the client’s ambivalence, the clinician and client together determine the direction of the change conversation through focusing. When focusing, agreement is reached on a specific agenda. The scope of the change conversation can center on a behavior change goal as well as therapeutic targets that are less concrete, such as a decision or a cognitive process (Naar & Safren, 2017). When evoking, the clinician strengthens the client’s own motivation and commitment to achieve the agreed-upon goal by eliciting and selectively responding to client language that is supportive of change. During this process, the clinician skillfully guides the client in the direction of change. Planning, in which the clinician and client formulate a specific and concrete action plan, takes precedence when the client’s ambivalence has faded and, based on the client’s language, there is momentum building to transition from talking about change to taking steps to enact change. Each process builds upon the previous one, creating a framework for clinicians to use to determine how to apply the spirit and core skills of MI with their clients. Awareness of this sequence is essential because failure to successfully complete the tasks of one process inevitably results in problems in addressing the tasks of the other processes. Without a strong therapeutic relationship established through engaging, it is unlikely that the counselor and client will agree on a meaningful change goal to discuss together. Similarly, with no clear direction determined, the clinician may try to elicit change talk related to a goal that the client has no interest in changing; thus, making evoking ineffective. Although engaging, focusing, evoking, and planning represent discrete phases in the change conversation, with each possessing a unique set of tasks, the four processes overlap and can sometimes repeat (Miller & Rollnick, 2013). The four processes overlap because as the interaction unfolds, the “completed” tasks remain in the background to be monitored and revisited when necessary. For example, if a client appears hesitant to develop an action plan during planning, the clinician can redirect the conversation toward strengthening change talk to bolster the client’s perceived importance and confidence to change, thus returning to evoking. The overlapping and cyclical nature of the four processes of MI captures the complexities of providing services to clients in clinical mental health settings. It is not uncommon for clients’ treatment goals to evolve and change over the course of counseling, as their self-awareness and recognition of the factors that contribute to their difficulties increases. In MI, clinicians and clients can revisit the important tasks of engaging and focusing when new treatment goals emerge, and plans shift. The amount of time spent addressing the tasks of a process largely depends on the client and setting. There are times when certain processes can be relatively brief; for example, clients who enter counseling to receive

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a specific kind of treatment for a clearly defined problem, such as exposure and response prevention therapy to treat obsessive-compulsive disorder, may need less time focusing. Decisions might still need to be hashed out about the specific details of the treatment approach, but the therapeutic target is generally clear. Sometimes processes require additional attention, such as engaging with clients who are mandated to treatment. The amount of time and structure of treatment also is a consideration. A clinician and client can cycle through the processes multiple times to address the various change goals that are salient at different points in counseling. Given the variability of how MI can be applied with clients, it is essential that clinicians know how to apply the MI core skills to successfully address the tasks associated with each specific process. The Engaging Process The bedrock of MI, and counseling in general for that matter, is establishing a relationship with the client that is grounded in mutual trust and respect (Miller & Rollnick, 2013). During the engaging process, the clinician makes efforts to develop a partnership with the client. This collaboration enables the client to play an active role in counseling and sets the stage for later efforts to jointly determine focus and cultivate change talk into strengthened commitment to change. Without a trusting and respectful relationship, clients are less inclined to self-disclose and take risks in counseling. In a phenomenological study of client experiences in MI, Zuckoff (2001) found that clients were more likely to engage in self-exploration when they perceived that they were not being judged or controlled by the clinician. Within an environment that fosters psychological safety, clients are free to engage in self-reflection and exploration of topics that they may otherwise try to hide to avoid possible social sanction or experience of negative emotions, such as guilt and shame. Miller and Rollnick (2013) described six traps that clinicians can fall into early in counseling that can reduce client engagement and perceived psychological safety. The assessment trap refers to clinician efforts to collect data at the expense of treating the client as an active and equal partner. In other words, asking a lot of questions to gather information signals to the client that the clinician is in total control. Structuring counseling so that the clinician asks questions to diagnose and then solve the client’s problems is referred to as the expert trap. Clinicians fall into the expert trap when they assume that the client’s problems can be fixed by asking the right questions and offering the correct solution, instead of treating the relationship as a partnership that welcomes the client’s own views. The premature focus trap occurs when clinicians choose a problem to focus on in counseling before they understand the problem within the greater context of the client’s life. This can lead to disagreement between the clinician and client in the focus of counseling. Exploring the client’s

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concerns and immediate needs can prevent this trap for occurring; for example, reducing non-suicidal self-injurious behavior may be less salient for a client who needs assistance securing stable housing. The labeling trap is when a clinician views a client as a label or problem (e.g., “you are bipolar”), rather than as a person. The use of labeling can reflect a power struggle between the clinician and client, in which the clinician assigns a label to the client to exert control. Unsurprisingly, labeling can produce discord if the client disagrees with the clinician’s categorization. Clinicians fall into the blaming trap when they engage in a struggle to determine who is at fault for the clients’ problems. Miller and Rollnick (2013) suggest that when clients wish to discuss who is to blame for their problems, clinicians should redirect the conversation by emphasizing that determining blame is not as important as addressing the client’s immediate needs. Finally, the chat trap is when the clinician engages in excessive informal small talk with the client, which keeps the conversation superficial and thus takes time away from exploring the client’s concerns and goals for treatment. Rosengren (2018) offered three guidelines for clinicians to consider during the Engaging process to avoid the pitfalls of Miller and Rollnick’s (2013) disengagement traps and to develop a deeper understanding of the client. The first is to create an environment that is welcoming and safe. In Zuckoff’s (2001) study of client experiences in MI, he found that client perceptions of psychological safety increased when clinicians used complex reflections to convey understanding and acceptance. Clinicians also can create this environment using affirmations. Genuinely pointing out client effort and strengths, for example, demonstrates respect and a sense of prizing by the clinician that can reduce anxiety and promote engagement of the client. Rosengren’s (2018) second guideline is for clinicians to “ask and listen” (p.  53) to better understand the client’s problems and reasons for coming into counseling. Using open-ended questions and reflective listening, the clinician attempts to understand the reasons why the client has entered counseling and how these reasons for counseling fits within the client’s life. This sheds light on the perceived importance of the presenting concern to the client and what the potential barriers of change are that have kept the client in a state of ambivalence. Without this information, it is unlikely that the clinician and client will be able to settle on a meaningful goal for counseling. The clinician also should listen for and explore client strengths, values, and goals, which provide added insight into the client’s change dilemma and can be revisited when evoking change talk and planning for change (e.g., exploring a client’s values and strengths can help evoke ability and need change talk). Clinicians should consider ways reflective listening can be integrated into the initial phase of counseling, which often include the use of formal assessment measures and a structured clinical intake interview.

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Third, Rosengren (2018) recommends that clinicians offer modest chunks of information in response to any gaps in understanding that clients have about their present situation. This includes providing information about counseling services and the ways in which the clinician can help. Additionally, it is important for the clinician to offer the client hope that change is possible. Drawing upon past client experiences, the clinician can present the client with a realistic picture of the effectiveness of counseling. Clarifying the ins and outs of treatment and offering hope also can increase the client’s confidence in being an active participant in counseling. By creating an environment that is safe and trusting as well as grasping the client’s needs and presenting concerns, the clinician lays the foundation in which subsequent processes are built upon. The relationship established when engaging enables the next process, focusing, to be a collaborative conversation between equal partners. Before advancing onto focusing, clinicians should have confidence that they (a) established an atmosphere of collaboration and psychological safety and (b) understand the client’s change dilemma, including the barriers that maintain the ambivalence as well as the strengths and values that can be brought to bear later to strengthen the client’s commitment to change. The Focusing Process MI is goal-driven and directional in nature (Miller & Rollnick, 2013). Using the core skills and spirit of MI, clinicians skillfully guide their clients toward deciding about change. The direction that the clinician guides the client in is determined during the focusing process. Depending on the circumstances, the direction might be a general topic or goal (e.g., improve mood, reduce worry) or more specific targets (e.g., improve mood through behavioral activation, reduce worry using cognitive restructuring techniques). Ultimately, what is important is that the focus is determined collaboratively and that it is clear to both the clinician and client where the conversation is headed. Without focusing, MI can feel rudderless. With no clear direction, it is unlikely that a clinician can act as an effective guide. Imagine going on a vacation without knowing the name or location of your destination. Bypassing focusing also can result in discord within the clinician-client relationship. This can occur if the clinician makes assumptions about what the client needs to focus on or determines the focus unilaterally without involving the client. This may lead to the client and counselor moving in different directions, or the counselor pulling the client in a particular direction. Focusing should be collaborative in that the clinician and client negotiate the scope of the change conversation. The extent to which negotiations are necessary depends on the specific sources of agenda at play.

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There are three sources of agenda that can contribute to determining the focus in MI. First and foremost, is the client. It is crucial to understand the clients’ aspirations, goals, concerns, and expectations for counseling (Miller & Rollnick, 2013). If there is a match between the client’s goals and the clinician’s scope of practice, a direction can be set without much negotiation; however, there are times when other sources of focus come into play and require greater discussion of the agenda. A second source of focus is the clinical setting. If the client has entered a clinic that provides a specific type of treatment (e.g., a program for complex trauma that offers Eye Movement Desensitization and Reprocessing therapy), for example, the clinician should offer information on these services and ascertain how the predetermined focus of the setting matches the client’s goals. A third source of focus is the expertise of the clinician. A clinician might wish to address an area relevant to a client’s presenting concerns that the client has yet to consider. For example, a clinician might identify the role that a sedentary lifestyle plays on a client’s low mood before the client makes this connection. When pursuing a focus based on clinician expertise, it is crucial that the clinician is transparent about this agenda and makes efforts to help the client recognize how the clinician’s desired focus fits with the client’s goals. Offering information in a manner that is consistent with MI spirit (e.g., Ask-Share-Ask) can help. The approach of the clinician during the focusing process will depend on the clarity of the possible direction for counseling (Miller & Rollnick, 2013). If the agenda is clear, based on the setting, clinician expertise, or the client’s own goals, the clinician and client transition into the next process, evoking. Once an agenda is set, is it important to determine the client’s motivation to address it. If the client is already motivated to change, the clinician should pass directly into the process of planning. Evoking change talk with a client who already is highly motivated to change can increase ambivalence and lead to discord. Imagine that while driving to visit a friend you become lost and must pull over and ask for directions. Instead of providing the directions, the person you ask for help responds by asking you questions about why your friend is important to you. For most of us, this experience would be rather irritating and perhaps also a little unsettling. Given the complex nature of the problems that clients in CMH settings present with, it is more likely that the clinician will have to help the client narrow down the possible topics to focus on to settle on a direction. Agenda-mapping (Miller & Rollnick, 2013) is one approach clinicians can use to assist clients in identifying possible focuses and to decide on where to start. When agenda-mapping, the clinician begins by writing out a list of possible topics of focus that have been raised by the client. Creating this list should be collaborative, with the clinician inviting the client to add new topics or amend ideas that were suggested by the clinician. Once a list has been made, the clinician uses open-ended questions

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and reflections to assist the client in exploring each of the possible topics. Sometimes it is helpful to have the client rank order or explore the topics by urgency to determine which should be addressed first. During this process, clinicians balance providing their opinions about possible topics with supporting the client’s autonomy in deciding on the focus. Because of the collaborative nature of MI, deference should be given to the client’s preferences. After a decision is made, the map can be revisited later if the agenda needs to be revised so that new goals can be introduced. Using a visual aid during this process is helpful (for more information about a formal instrument to monitor agenda-mapping and focusing, see Gobat et al., 2015). Agenda-mapping can be a helpful process for clients who are overwhelmed by the many problems they face. Mapping out these problems can increase the client’s sense of control. Further, revisiting the map later in counseling can help increase the client’s confidence by serving as a reminder of the progress that has been made over time. Agenda-mapping only is possible when there is some clarity around potential topics that can be the focus of the conversation. When an agenda is unclear to the client and clinician, it requires a more complex and nuanced process of orienting (Miller & Rollnick, 2013). Consider clients who can describe the problems that have brought them into counseling but respond to questions about possible treatment goals with “I don’t know” or some variation. In these cases, it is helpful for clinicians to use reflective listening to identify possible paths forward. By listening with curiosity to the client’s presenting problems and the ways that the client has tried to address these concerns in the past, the clinician can offer possible new ideas on how they can move forward together. One way of doing this is to respond strategically to problem statements in a manner that brings to light possible solutions or treatment goals. For example, in response to the statement, “I am too disorganized to do anything” from a client who struggles with activities of daily living, the clinician can offer this reflection: “You want to learn some new skills that can help get you back on track.” If multiple ideas are generated through orienting, the clinician can engage the client in agenda-mapping to prioritize which topics to address first. Whatever the source or clarity of the agenda, focusing on MI should be collaborative with specific attention given to supporting client autonomy. This is especially important when clinician and client goals differ. Clinicians should resist the righting reflex and not try to persuade their clients to agree on a particular goal. Rather, reflective listening should be used to explore the client’s concerns. When determining how to respond to an impasse in focusing, clinicians also must consider what is in the best interest of the client. If there is disagreement over two possible goals, the clinician should defer to the client’s wishes; however, if the clinician determines that the clinician’s goals address an imminent risk to the client, the

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clinician should explore and evoke around that goal to increase the client’s motivation to take it on. Exploring how the clinician’s goal is consistent with the client’s values and life goals is one way to enhance client interest in pursuing a particular path forward. Ultimately, the counselor should rely on MI spirit as well as the ethical values of nonmaleficence and beneficence when negotiating with a client a potential direction or target to address (Miller & Rollnick, 2013). One way to negotiate an impasse in focusing is to collaboratively agree on two separate paths forward: what the client wishes to address as well as the focus that the clinician sees as imminent. This process of negotiation should involve some discussion of when (e.g., how much time per session will be spent on each focus?) each focus will be addressed in counseling. The Evoking Process Once a therapeutic target has been identified, the clinician evokes and responds to client arguments that favor change. One way to evoke change talk is to ask questions that directly elicit the client’s desire, ability, reasons, and need to change (e.g., “What is the most important reason why you want to make this change?”). When change talk emerges, it is crucial that the client expand upon these arguments for change. Researchers have found that the number of different client change talk statements uttered in session does not predict outcomes in MI and have argued that the quality or depth of the change talk is more important in facilitating change (Magill et al., 2018). In addition to asking for elaboration, a clinician can promote exploration of change talk using reflective listening. Reflecting back change talk is like holding up a mirror to the client. Reflections allow clients to hear again and fully absorb each argument for change. Two targets of evoking are the client’s perceived importance and confidence in making the change. Whereas eliciting and reflecting desire, reasons, and need to change can strengthen a client’s perceptions of the importance of change, attending to ability change talk can enhance one’s perceived capacity to enact change (i.e., confidence). Affirming personal strengths and efforts to change are two other ways to bolster a client’s self-efficacy (e.g., “You are a hard worker who will do what it takes to make this change happen”). This kind of clinician feedback is evidence that challenges client beliefs about not being able to follow through with the desired change. This is a good example of how strengthening change talk also can soften sustain talk. Reviewing past successes, such as by exploring times in the past when the client has successfully made a similar change, is another way to strengthen confidence. As importance and confidence increase, momentum builds within the client to come to a resolution about change. Several signs indicate that the client is ready to begin planning for change. A decrease in sustain talk and increase in change talk signal that

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the client may be ready to act (Miller & Rollnick, 2013). This increase in change talk includes arguments reflecting the pro side of change (i.e., desire, ability, reasons, and need) as well as statements that represent growing commitment to change. Commitment and activation change talk often emerge when clients begin to envision and ask about what it would be like to change, which are other indications that it may be time to transition into planning. Finally, perhaps the most obvious sign that the client’s ambivalence has been resolved is when the client begins taking steps toward change. After observing some of these signals, the clinician should test whether it is time to transition into planning. Miller and Rollnick (2013) recommended that clinicians offer a summary that brings together the client’s strongest arguments for change. Rosengren (2018) provided a framework for organizing this summary: (a) begin with a statement that indicates the clinician will now bring together what the client has said, (b) provide a brief overview of the client’s initial ambivalence to change, (c) share the most meaningful change talk that has since emerged, and (d) inquire about possible next steps. Asking about next steps (e.g., “where do we go from here?”) is an invitation to consider whether to start planning and not an attempt to secure a promise to change, which can lead to discord if the client is not ready to commit (Rosengren, 2018). A client’s response to a simple open-ended question, such as “what’s next?” signals whether to proceed to planning or to continue evoking and strengthening change talk. The Planning Process During the planning process, the client develops a plan to implement change. Though action-oriented treatment modalities, such as cognitive behavioral therapy, can be helpful when planning, the clinician should continue to embody the spirit of MI during this process. First and foremost, this means that the change plan should be evoked from the client. Using evocative questions (e.g., “how can you make this change?”), the clinician helps the client move from envisioning change to developing an action plan. If the client is unable to formulate a strategy for enacting change, the clinician can provide guidance; however, advice should be given in a way that promotes partnership and acceptance. This can be done by asking permission first and providing the client with a menu of options to choose from (Miller & Rollnick, 2013). These strategies support client autonomy (i.e., even though the ideas for planning came from the clinician, the client still has some say in how to proceed) and can lead to a collaborative discussion on which of the presented options are most feasible for the client to try out. When formulating a plan, it is important that clinicians use their expertise and understanding of the change process to set their clients up for success. Goals set by the client should be realistic because failure

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to achieve change goals reduces self-efficacy and intensifies sustain talk and ambivalence to change. Goals should be specific so that the client and clinician are able to determine how effective the client was in enacting them. Lewis et al. (2017) described how the Goal Attainment Scale (GAS; Ottenbacher & Cusick, 1993) can help clients develop concrete plans to implement change. Once a goal has been specified, the clinician and client develop a personalized scoring system that allows for regular monitoring of the client’s performance in carrying out the goal. Data gathered from the GAS can be used to help bolster client confidence or, in the case of setbacks, inform the planning of new and more realistic change goals. In addition to setting specific and attainable goals, clinicians should prepare their clients for potential obstacles when implementing their change plan. No matter the amount of planning, there is the possibility (perhaps certainty) that challenges will arise that can derail one’s plan. Clinicians can help clients plan by brainstorming possible barriers and adaptive responses to these obstacles. Rosengren (2018) recommended having clients develop “if-then” statements that outline responses to potential obstacles (e.g., if I call my friend to go to the gym with me and she does not answer the phone, then I will go on a walk by myself for 20 minutes). Some may question the utility of evoking barriers to change, which are a kind of sustain talk, when planning. At this point in the change process, however, clients should be able to articulate ways to address these barriers, which softens the sustain talk and increases the likelihood of the change plan succeeding. Therefore, the advantages of exploring barriers with potential solutions in advance outweigh the benefits of not attending to them until later after they occur. When developing a change plan, it can be helpful for the clinician to evoke change talk that reaffirms the client’s commitment to change (Miller & Rollnick, 2013). Even when one’s ambivalence to change is resolved, there may still be some lingering hesitancy to enact change. Asking questions to evoke and encourage elaboration of commitment and activation change talk can strengthen the client’s determination. Time spent evoking mobilizing change talk will vary depending on the client’s motivation to change. This process may not be as necessary when the client shows a clear commitment to change. Nonetheless, it is beneficial to explore commitment during the planning process and implementation of the change goal. Involving others in the change plan, is another way to increase the likelihood that a client’s intentions to change will translate into action. Table 4.1 includes several questions that a clinician can use to help guide the planning process. Let’s now turn to the application of these four processes within a clinical mental health setting. In the case study below, we follow a client through the four processes of MI, with elaboration on each process and its relation to the case.

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Table 4.1 Questions to Guide the Planning Process Topic

Question

Target Strategies Cues to action

What I plan to change: Steps I plan on taking to make this change: Reminders I can add to my environment to carry out my plan: People in my life who can help me: I am committed to making this change because: Potential barriers and adaptive responses: How I will know that my plan is working:

Supports Consolidating commitment Obstacles and solutions Outcomes

Case Study Carol is a 25-year-old African American single-mother referred to community agency through her Employee Assistance Program (EAP). Since giving birth to her first child, now six months old, Carol has reported depressed mood, difficulty concentrating, and feelings of guilt and anxiety. Her symptoms have intensified since returning to work four months ago. Carol has sought support from her family; however, they have minimized her struggles as normal “baby blues” that will pass if she focuses on “all that she has to be grateful for in her life.” At work, Carol spends most of her time worrying about her child or ruminating on beliefs of worthlessness. These cognitive processes, combined with her difficulty staying on task, have had a negative impact on her job performance. After overhearing Carol sobbing in her office, her supervisor helped set up her contact with the EAP. Carol’s supervisor is a caring yet stern person, who has encouraged her to get some help before she loses her job. Although Carol is grateful for her supervisor’s show of support, she is hesitant about seeking mental health treatment. In her initial session, she admits that she did not tell her family about where she was because of their distrust of clinical mental health and medical professionals. Engaging When engaging, the counselor seeks to understand the client’s ambivalence and establish a strong therapeutic relationship. Building a strong relationship with Carol appears to particularly important given her reluctance to enter counseling. This may be attributed to cultural norms related to African American women needing to be strong and care for others in times of distress (Avent-Harris et al., 2019) as well as stigma around formal help-seeking and mental health treatment among African Americans (Avent-Harris et al., 2020). In the following exchange, the counselor uses open-ended questions to explore Carol’s hesitancy in seeking help and how her depressive symptoms have upended her life.

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Complex reflections are used to convey understanding and empathy, and affirmations are offered by the counselor to underscore strengths and positive efforts made thus far by Carol. CAROL: I shouldn’t feel this way. I have a beautiful and healthy baby girl. COUNSELOR: You are not feeling like yourself lately. CAROL: And, I am so embarrassed that my boss heard me crying, I should

be able to pull myself together and get my work done. You have been doing a lot of crying lately and you want it to stop. CAROL: I don’t know. I feel sad all of the time. COUNSELOR: It is exhausting to balance everything in your life while feeling the way you do. CAROL: I wish that I could get back to the way things were before the baby. You know, like flip a switch and be happy again. COUNSELOR: So far you haven’t been able to flip that switch on your own. CAROL: Yes. I keep thinking that one day I am going to wake up and everything is going to be better. And when that doesn’t happen, I feel bad. COUNSELOR: Carol, it says a lot about you that, despite how ashamed and overwhelmed you are feeling now, you are open to speaking with me and getting some support. CAROL: If my mom knew I was here, she would be horrified. COUNSELOR: So far you have mentioned a few reasons why talking to a counselor is strange for you. I’m wondering, what are some potential benefits of counseling? COUNSELOR:

Based on this brief exchange, it seems like Carol is experiencing clinically significant distress that is impacting her functioning. The counselor used several complex reflections that acknowledged Carol’s difficulties and helped guide the direction of the conversation toward discussing what their next steps will be together. This included recognizing Carol’s desire for things to be different. When exploring Carol’s help-seeking beliefs, the counselor sought to understand both arguments, for and against participating in counseling. As this exchange continues, the counselor will validate Carol’s experience and explore possible values and strengths that can support her desire to feel better. Focusing The purpose of focusing is to clarify a direction for the conversation. This includes identifying a specific target or goal for change that the counselor and client will address in counseling. The agenda that is set is influenced by three sources: the client, counselor, and setting. When focusing, the counselor will explore Carol’s thoughts on how she wants to move

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forward and strategically offer information to increase her awareness of approaches that have been effective in treating similar cases. Openended questions and reflective listening will assist Carol in considering her options and deciding on a direction. COUNSELOR:

So far, a number of possible directions forward have emerged. You are hesitant about trying out medication to improve your mood. That said, you are willing to speak to our staff psychiatrist about whether antidepressants are a good fit for you. In terms of counseling, you like the idea of continuing to see me on a regular basis, but you didn’t want these sessions to be a time when you just fall apart and cry the entire time. CAROL: Yeah, I don’t know about taking medication. I think that I could use the added support, but I am not sure what we’d discuss. COUNSELOR: The people you’d typically go to for support are making you feel worse, so counseling could be a set time in your schedule that can help you feel better. CAROL: But I don’t feel comfortable coming in every week just to tell you about how bad things are in my life right now. COUNSELOR: You want these sessions to be productive. You want to do things here that make you start feeling better. CAROL: Yes. But everything I’ve tried hasn’t worked. COUNSELOR: May I share with you some examples of the types of things my past clients, who have gone through similar experiences, have said they benefited from? CAROL: Sure. COUNSELOR: Some of my clients have said that learning new coping skills really helped them with their depression. That might mean practicing new ways of responding to the negative thoughts you described earlier, exercising more or doing yoga. It also could be scheduling activities into your day that bring you some pleasure. One’s life can become pretty disjointed and chaotic after having a baby; counseling can be a place where you can regroup and learn new more healthy and positive ways of living. What do you think? CAROL: You know, before the baby I used to have a life that included spending time with friends and getting out of the house, besides going to work, daycare, and Target. COUNSELOR: Socializing with friends is one activity that might help you feel better. CAROL: I just don’t know if I have time for “pleasurable” activities. COUNSELOR: At this point, it seems impossible to imagine things in your life changing. CAROL: I wouldn’t say impossible. I don’t know, maybe reaching out to my friends might help. I am just not sure about what that will look like. COUNSELOR: One thing that we can do together is brainstorm ways that you can fit activities into your day that will help you feel better.

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The exchange begins with a summary of the possible directions forward. The client has agreed to a psychiatric consult and appeared willing to continue with counseling. After it became apparent that the client was unsure of the ways that counseling could be beneficial, the counselor used Ask-Share-Ask to provide some examples of possible tasks that can be the focus of their work together. Importantly, the counselor asked permission before providing the information, to support Carol’s autonomy, and checked in after offering the different options for treatment to promote client engagement. The client appeared most interested in scheduling pleasurable activities to improve her mood; hence, the counselor transitioned to exploring that approach. This could include sharing with Carol steps associated with behavioral activation, which is a promising approach to treating perinatal depression (Sockol, 2015). As this exchange continues, other ideas for treatment goals and tasks may arise. If that happens, the counselor can use agenda-mapping to help the client narrow down the possible directions forward and agree on a set of goals and tasks to start with in counseling. Evoking When evoking, the client’s arguments for change are elicited and strengthened by the counselor. By identifying and expanding upon the “why” of making the change, the counselor guides the client toward the process of planning, or the “how” of change. In other words, exploring all the contours of our clients’ best arguments for change can help increase their determination to act. The exchange below occurs later in counseling as Carol explores ways to decrease her social isolation and reengage in activities that provide her with a sense of pleasure and mastery. One specific activity that Carol is willing to consider is reconnecting with her friends; however, she has some ambivalence about making this change to her schedule. The counselor uses open-ended questions, affirmations, and active listening to strategically draw forth and help strengthen Carol’s motivation to begin her behavioral activation plan. CAROL:

I’d like to see my friends more, but between work and the baby, there is no time. COUNSELOR: You really want to make some space in your schedule to reconnect with them. CAROL: Yes, I texted with a friend the other day and it was nice. COUNSELOR: How was it nice? CAROL: My friend Sarah texted me to check in, which was nice. She has young children and is working now so she kind of knows what I am going through. We ended up sharing stories about how stressful it can be to try and balance everything. COUNSELOR: Even that quick text with Sarah improved your mood a little. CAROL: I guess it did. It felt good to reconnect. We used to be really close.

70 Foundations of Motivational Interviewing COUNSELOR:

Having more of these kinds of interactions will help you feel better. CAROL: Yeah. COUNSELOR: How might doing the activities we’ve discussed so far help? CAROL: I felt really alone after giving birth. Like it was just me and the baby. Seeing my friends helps with that. COUNSELOR: What else? CAROL: We talked about how when I am alone, my thoughts can go to very dark places. So I guess being around people I am comfortable with keeps me out of my head. COUNSELOR: You value friendship and the impact that connecting with others has on you. CAROL: Yes, but I don’t think that it is possible that I will be able to do all of the things that we have discussed so far. I think that it will help, but I feel pretty overwhelmed. COUNSELOR: It is important to set goals that are realistic. Carol is ambivalent about increasing her engagement in activities that will help decrease social isolation and increase opportunities for pleasure and joy. During this exchange, the counselor responded strategically to keep the focus on change talk. Open-ended questions were used to elicit reasons for engaging in behavioral activation and the counselor used reflections and an affirmation to strengthen Carol’s desire to reconnect with her social network. Evoking is not a time to give equal attention to both sides of change; as demonstrated earlier, the counselor favored change talk over sustain talk when offering reflections. As this exchange continues, the counselor will continue evoking and encouraging elaboration of change talk. The counselor may even use immediacy to point out changes in Carol’s demeanor and affect as she describes recent examples of when she has reconnected with her friends. These efforts will help to increase her commitment and motivation to take action. Planning One sign that clients are ready to transition into the process of planning is when they begin to envision making the change (Miller & Rollnick, 2013). Clients who are envisioning what change will be like share their intentions and possible ways to change. This mobilizing change talk is a signal for the counselor to switch gears and focus on helping the client plan for change. In the exchange below, Carol has decided that she wants to add more interactions with her social network into her schedule. The counselor begins with a recapitulation of key change talk that has emerged in their conversation followed by a key question inviting Carol to consider her next steps. Open-ended questions and reflections

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are used by the counselor to guide Carol in creating goals and a concrete change plan. COUNSELOR:

So far we discussed a number of reasons why it is important for you to reconnect with your friends. Being around others helps you to stay out of your head. It improves your mood. That boost gives you more energy when you are with your baby and tackling other challenges. Seeing them makes you feel like things are starting to get back to normal. I’ve even noticed your mood brighten as you talked about chatting with your neighbors and texting your friends. CAROL: Yes, you are right. COUNSELOR: What might it look for you to do more social activities during the next week? CAROL: My neighbor is always willing to go on walks with me in the evening. We watch the same trashy shows, so I enjoy hanging out with her. I probably could make plans to meet her some days to go on walks around the lake. COUNSELOR: So you plan on setting up an “ongoing appointment” to walk and talk with your neighbor. Starting when? CAROL: She’s always stopping by on Mondays, and I think Thursdays. COUNSELOR: Twice a week. And what if she doesn’t stop by tomorrow? CAROL: I probably can text her before I drive home today. She’s good with responding. COUNSELOR: That’s a great idea! What are some other ways that you can reconnect with others? CAROL: I’m so tired at night, I don’t think that happy hour is an option. COUNSELOR: I can imagine that you are very exhausted after finishing your day. What are some other ideas you have to reengage with your friends, like Sara, that are realistic? CAROL: I liked texting with her. I don’t think that calling her will work because she has kids too. COUNSELOR: Texting her or some of your other friends is something that you could try out. During the planning process, the counselor can sound almost like a coach helping the client identify realistic goals and solidify goal-related action steps. The recapitulation summary included several of Carol’s most important arguments for increasing her social engagement. In the opening summary, the counselor also tried to soften Carol’s sustain talk that spending time away from her baby makes her a bad mother by restating how taking time for herself helps her be more engaged and present when she is with her child. Given Carol’s openness to try out activity scheduling, the counselor asked several questions to help her start developing a concrete plan. As they mapped out a plan, the counselor attempted to

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model adaptive problem-solving by helping Carol consider and prepare for the potential barriers that could interfere with her plans.

Summary Engaging, focusing, evoking, and planning serve as the four key processes of MI and allow clinicians to understand what MI “looks like” in session. From the engaging process, we strive to build rapport, lower discord, and remain curious about the client’s perspective on change and the change process. In focusing, clinicians home in on a target for exploration and change. With evoking, clinicians intentionally pull out from clients their own arguments for change, primarily by elaborating, affirming, reflecting, and summarizing change talk. Finally, planning strengthens one’s commitment to change and encourages taking actionable steps to change. Activities and Resources 1. Develop a list of OARS for each MI process (Engaging, Focusing, Evoking, and Planning). 2. Practice with a partner using the change questions in Table 4.1. The speaker should talk about a professional goal (e.g., using MI) and the listener should use the questions in Table 4.1 to guide the conversation.

References Avent-Harris, J. R. (2019). The Black Superwoman in spiritual bypass: Black women’s use of religious coping and implications for mental health professionals. Journal of Spirituality in Mental Health, 1–17. https://doi.org/10.1080/19 349637.2019.1685925 Avent-Harris, J. R., Crumb, L., Crowe, A., & McKinney, J. (2020). African Americans’ perceptions of mental illness and preferences for treatment. Journal of Counselor Practice, 1–33. https://doi.org/10.22229/afa1112020 Gobat, N., Kinnersley, P., Gregory, J. W., & Robling, M. (2015). What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation. Patient Education and Counseling, 98(7), 822–829. https://doi. org/10.1016/j.pec.2015.03.024 Lewis, T. F., Larson, M. F., & Korcuska, J. S. (2017). Strengthening the planning process of Motivational Interviewing using goal attainment scaling. Journal of Mental Health Counseling, 39(3), 195–210. https://doi.org/10.17744/ mehc.39.3.02 Magill, M., Bernstein, M. H., Hoadley, A., Borsari, B., Apodaca, T. R., Gaume, J., & Tonigan, J. S. (2018). Do what you say and say what you are going to do: A preliminary meta-analysis of client change and sustain talk subtypes in motivational interviewing. Psychotherapy Research, 29(7), 860–869. https:// doi.org/10.1080/10503307.2018.1490973 Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. Guilford Press.

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Naar, S., & Safren, S. A. (2017). Motivational interviewing and CBT: Combining strategies for maximum effectiveness. Guilford Press. Ottenbacher, K. J., & Cusick, A. (1993). Discriminative versus evaluative assessment: Some observations on goal attainment scaling. American Journal of Occupational Therapy, 47(4), 349–354. https://doi.org/10.5014/ajot.47.4.349 Rosengren, D. B. (2018). Building motivational interviewing skills: A practitioner workbook. Guilford Press. Sockol, L. E. (2015). A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. Journal of Affective Disorders, 177, 7–21. https://doi.org/10.1016/j.jad.2015.01.052 Zuckoff, A. (2001). Motivational interviewing: An empirical-phenomenological study of the interpersonal process and client experience of a counseling style [Unpublished doctoral dissertation]. Duquesne University.

Part II

Applications of Motivational Interviewing in Clinical Mental Health Settings In Chapters 5–9, we take the principles, skills, and processes of MI learned in Part I and show how they can be applied across the many facets of clinical mental health (CMH). Chapter 5 examines the application of motivational interviewing (MI) across common presenting concerns clients bring with them to counseling. In Chapter 6, we examine the use of MI in a group format. Group counseling has emerged over the years as an effective, efficient form of counseling, and most CMH agencies offer a range of groups for their clients. Case conceptualization and evaluation are the topics of Chapter 7, and the reader will see unique contributions MI can make to these important activities. In Chapter 8, MI is examined as a strategy for clinical supervision, a critical process within mental health care. Part II concludes with Chapter 9, which looks at the everincreasing diversity within CMH agencies and MI’s usefulness across a range of diverse clientele. Each chapter includes a case study to demonstrate MI across these common actions within CMH agencies. Chapters conclude with activities and resources designed to assist mental health counselors in their application of MI.

DOI: 10.4324/9781351244596-6

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Introduction Clinical mental health (CMH) settings, both inpatient and outpatient, assist individuals who struggle with mental and emotional problems, many of which are diagnosable conditions according to the DSM 5. Motivational interviewing (MI) has expanded far beyond an approach to address addictive behavior, even outside the general fields of counseling and therapy (e.g., dentistry, education). As you will see in this chapter, the list of clinical disorders and problems that MI can address has expanded greatly and continues to expand. The success of MI in treating addictive and health-related conditions has naturally raised the question of its effectiveness for other mental health issues. Although more rigorous research is needed using MI with common mental health disorders, the available evidence is encouraging (Arkowitz et al., 2015). There are three primary reasons for its effectiveness: First, MI encourages and promotes change talk, and cultivating this change language encourages clients to move in the direction of change (change talk was covered extensively in Chapter 3; Arkowitz, Miller, & Rollnick). Second, MI provides a humanistic atmosphere and spirit that is facilitative toward change. When provided this therapeutic milieu, clients naturally move in the positive direction. Third, MI encourages conflict resolution, primarily through helping clients resolve ambivalence. It is this resolution that helps clients become unstuck in their lives, moving toward a more preferred way of living (more on this below). Below are some specific ways practitioners counsel clients in CMH settings using an MI framework. 1. Working with discrepancies. Miller and Rollnick (2002) noted that without discrepancy between goals and values, on the one hand, and behaviors on the other, MI can be difficult to apply. We certainly concur with this sentiment. Developing discrepancy within the client builds cognitive dissonance, which is inherently motivating. Clients who recognize that how they are behaving is inconsistent with their goals and DOI: 10.4324/9781351244596-7

78 Applications of MI in CMH Settings values feel a natural motivation to lower the dissonance. In outpatient settings, MI practitioners intentionally explore values and life goals, followed by gently pointing out behaviors that regularly sabotage clients’ happiness. For example, if a client experiencing major depressive disorder desires (values) to feel better, yet consistently entertains negative thought patterns, a discrepancy is illuminated to increase internal motivation to challenge these negative thought patterns. 2. Working with ambivalence. Ambivalence, covered extensively in Chapter 3, reveals itself with most clients who contemplate change; however, with anxiety and other mental health issues, it usually centers on following through with treatment protocols or difficult homework assignments (e.g., exposure exercises). MI practitioner’s work with ambivalence by exploring the pros and cons of the status quo versus the pros and cons of change, helping clients delve into mixed feelings about change, and thus “tipping the scales” in its favor. 3. Evoking change talk. Change talk is a key area of focus when practicing MI. MI practitioners are especially attuned to the language of change because, as we discussed in Chapter 3, the consistency and depth of change talk is predictive of change (Miller & Rollnick, 2013). Most clients who present at outpatient clinical settings want to change at some level, whether it be to lower depression, better cope with negative emotions, or simply to live with calm and focus. CMH counselors actively evoke the frequency and depth of change talk and help clients move toward ever increasing commitment to change. 4. Eliciting from the client. Clients who experience MI are often surprised that the counselor does not “tell them what to do.” To be sure, MI practitioners offer advice, but even that is provided with permission. Evoking the client’s own thoughts, feelings, and attitudes regarding change sends a strong message that what clients think matters, and their perspective is going to be honored in the counseling session. In the remainder of this chapter, we briefly explore the use and effectiveness of MI in inpatient and outpatient mental health settings, supported by the latest empirical evidence. The emphasis of the chapter will focus on extending MI beyond the addictions problems, including working with mood disorders, anxiety disorders, eating disorders, and medication compliance issues. Infused throughout the chapter is the use of MI in combination with other approaches. The chapter concludes with a case study, activities, and resources for additional information and study.

Using Motivational Interviewing in Inpatient Mental Health Care Settings Inpatient care settings include two general types: (a) medical detoxification/ stabilization and (b) hospital inpatient. Medical detoxification/stabilization is generally reserved for severe cases of substance use problems, where

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clients may need to have a medically supervised detoxification process (e.g., detox and withdrawal from alcohol, opiates, and cocaine). According to Perez (2005), detoxification is the complete, safe withdrawal from a substance. The supervised environment is needed because the client has reached a level of substance use that can be dangerous if he or she were to abruptly stop using. Although MI is not often associated with inpatient settings, it can be infused in all aspects of a medical detox process: (a) screening for withdrawal and other psychiatric symptoms, (b) onesite medical care to promote safe withdrawal, and (c) providing structure, protecting clients from self-harm, and educating/counseling clients about their drug use. Within screening, practitioners trained in MI can incorporate the OARS skills to reduce possible discord and resistance. Reflective listening can be a crucial component of safely withdrawing, as clients verbalize their frustration, pain, and struggle. MI, born out of the addictions field, would be a natural method to use in counseling clients related to their substance use and the possibility of change. Hospital inpatient is another inpatient care setting. Hospital inpatient settings are usually for clients who have one or more severe psychiatric conditions or those struggling with dual diagnoses (substance use and psychiatric problems). Significant problems in living, combined with substance use, increases the potential for self-harm or harm to others, necessitating a highly structured and restrictive environment. Mental health practitioners work collaboratively with physicians for medication management, individual and group counseling, and ongoing diagnostic evaluation (Perez, 2005). Other services include crisis stabilization, intensive assessment service, and, as clients improve, family counseling (Perez, 2005). As with medical detoxification and stabilization environments, MI has direct applicability within the hospital inpatient setting. MI has been found to be effective as a prelude to, or significant part of, treatment for a range of psychiatric disorders commonly found within inpatient settings, including depression (Naar & Flynn, 2015), PTSD and comorbid substance use (Yusko et al., 2015), suicidal ideation (Britton, 2015), and disordered eating (Cassin & Geller, 2015). Another important use of MI within inpatient settings is the training of physicians and inpatient nurses in the philosophy, techniques, and skills of MI (more on training and learning MI will be provided in Chapter 10). Often, practitioners can be more effective with a patient in a 15-minute consult with using MI compared to standard care (Rollnick et al., 2008). In other words, listening, evoking, and collaborating encourage openness to treatment options compared to being overly directive. We do not mean to suggest that MI should replace current practice in inpatient facilities. There are certainly times when a more directive approach is necessary and warranted. Rather, we agree with Rollnick et al. (2008), who suggest MI not as an approach to replace standard care, but to complement it. If physicians and medical personnel have an opportunity to utilize a more

80 Applications of MI in CMH Settings guiding style when behavior change is at issue, our bet is that they will produce more efficient and better outcomes.

Using Motivational Interviewing in Outpatient Mental Health Care Settings The outpatient CMH setting is less restrictive than inpatient settings and includes community mental health agencies, private practices, group mental health practices, and college counseling centers. Clients typically come in once a week for individual, group, family, or couples sessions lasting from 60 to 90 minutes. Intensive outpatient programs (IOP), however, usually require attendance several times a week. Outpatient settings do not typically handle emergency or crisis situations or, if there is a crisis, the client is quickly referred to an area hospital. Clients are not required to stay overnight at the facility, and medication management is usually completed with a staff medical professional or an outside medical specialist. Outpatient settings are best suited for clients who continue to struggle with significant mental and emotional concerns but are not at a level of dysfunction where there is immediate need for intensive care. Often, after an inpatient psychiatric stay, clients will continue with outpatient counseling to sustain mental health care. MI is well suited for general outpatient care. For clients who visit outpatient settings, significant personal barriers may be in the way of meaningful change. For example, clients might verbalize a desire to change, but hold substantial internal resistance to the counseling process or hard work they need do to change. Client expectations might be that they will be told what to do and that counseling will be a waste of time. Because of these possible issues, we advocate initially using MI with every client. Such an approach builds rapport, eases discord and resistance, and increases internal motivation before other therapeutic options are considered. Because of these therapeutic barriers, MI has been found to be useful in improving retention rates during the initial phases of treatment, especially for “difficult” client populations such as heroin users (Secades-Villa et al., 2004). The use of OARS, abundant reflection, and MI spirit can combine to be a powerful antidote to resistance and discord. Indeed, although there are several ways that MI can be used to help clients struggling with mental health problems, using MI to start things off is a great way to incorporate the method with demonstrated benefit. We now turn to the use of MI with common mental health problems.

Using Motivational Interviewing with Common Mental Health Problems Depression Depression constitutes a group of symptoms characterized by sad mood, irritability, and feelings of emptiness in addition to other emotional,

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somatic, and cognitive issues (e.g., negative thinking patterns). There are many depressive disorders in the DSM 5 (APA, 2013), including major depressive disorder, persistent depressive disorder, substance/medication induced depressive disorder, and other/unspecified depressive disorder. Low energy and motivation also are prominent symptoms reflected in these diagnoses. There are several elements of depressive symptomology that MI is uniquely qualified to address (Naar & Flynn, 2015). For example, motivational problems, ambivalence about making changes, and low selfefficacy are common depressive complaints for which MI can help improve. The optimistic nature of MI counters problem-saturated narratives frequently told by clients struggling with depression. Whereas MI may not directly address the emotional or cognitive symptoms of depression, it can be quite helpful in increasing behaviors that lead to positive feelings and experiences (e.g., behavioral activation). Physical activity, for example, is an emerging, innovative treatment for depression, and MI has the potential to resolve ambivalence about and increase motivation to exercise (Naar & Flynn). Motivational Interviewing as a Stand-Alone Treatment for Depression MI can be used as an approach in and of itself for the treatment of mild cases of depression. However, for severe depression cases, pure MI may not be enough. Why does severity matter in cases of depression? Because one of the symptoms of depression is lack of motivation or zest for life. When one is severely depressed, he or she may not have the baseline energy to even consider goals, values, importance/confidence of change, or other key MI strategies. Other methods, such as cognitive-behavioral therapy (CBT) and pharmacotherapy, may be warranted to improve client symptomology enough to where motivational considerations can take firmer root. In mild cases of depression, clients may present with higher levels of energy (they are sick and tired of feeling this way and want to change) and thus motivational issues can be explored. It is rare to seek pure MI as the only approach to treatment depression in the research literature. More likely is a combination of MI and other approaches. Motivational Interviewing Integrated Into Other Psychotherapies for Depression Empirical findings suggest that MI can be successfully integrated with other psychotherapies for depression, especially CBT and Interpersonal Psychotherapy (IPT; Naar & Flynn, 2015). The integration of these approaches uses MI to strengthen motivation to change, whereas CBT or IPT help clients develop cognitive, behavioral, and/or interpersonal skills to change (Burke, 2011). Although most research has focused on MI and CBT or IPT, we believe that MI can be integrated with almost any other counseling approach; mental health counselors can use MI to build

82 Applications of MI in CMH Settings motivation to change, while incorporating other approaches to build skills for change. In addition, the spirit of MI comprises the “ingredients of good practice” (Rollnick, 2010) and can be seen as foundational to counseling no matter the primary theoretical orientation that is used. For example, I (TFL) incorporate elements of Acceptance and Commitment Therapy (ACT) in my counseling work with clients struggling with depression. When using ACT, I introduce concepts that require substantial practice and “homework” to master the skills (e.g., diffusion). During this process, I ground the session in MI spirit (collaboration, evocation, acceptance, and compassion) and use MI to check in on motivation levels to carry out the homework. Engaging the client and eliciting his or her own ideas for skill practice increases ownership in the process, where clients feel that have a stake in their own counseling care. The impact is usually an increase in motivation. Anxiety Disorders Anxiety is one of the most frequent complaints within CMH agencies and manifests in several ways including restlessness, shakiness, uneasiness, feelings of fear or dread, avoidance, and worry. Anxiety disorders listed in the DSM 5 include generalized anxiety disorder (GAD), panic disorder, agoraphobia, specific phobia, and social phobia. Anxiety plays a key role in obsessive-compulsive disorder (OCD), although OCD has now been separated from the anxiety disorders and has its own chapter within the DSM 5 (APA, 2013). Of course, anxiety is not only relegated to specific anxiety disorders. Our clinical experience suggests that anxiety underlies many additional disorders in the DSM, including mood, psychotic, eating, personality, substance related, and sleep. Even though the experience of anxiety is not a formal criterion for these diagnoses, it nonetheless is present to some degree in many, if not most, clinical presentations. Motivational Interviewing as a Stand-Alone Treatment for Anxiety MI was originally developed to address ambivalent feelings about drinking. However, it is highly amenable to the treatment of anxiety related issues, especially when clients are ambivalent about change (Westra, 2012). When it comes to anxiety, clients often state they want to feel better and stop sabotaging their happiness. At the same time, change can be scary and there can be a strange sort of comfort in the status quo and not taking risks. Of course, this is the very nature of ambivalence; feeling two (or more) ways about a particular problem. When used as a treatment for anxiety, MI can help engage clients in the treatment process, focus on specific anxiety-based situations, elicit from clients their own ideas about change, and help the client formulate a plan to go about doing it.

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Although a common use of MI in the treatment of anxiety is to integrate it with other approaches (e.g., CBT), MI by itself has been shown to be an effective treatment. In a randomized study comparing motivational enhancement therapy (MET)1 with a psychoeducation control group in the treatment of anxiety sensitivity (AS; AS is the fear of the consequences of anxiety), clients in the MET condition demonstrated significant reductions in AS compared to the control group (Korte & Schmidt, 2013). In a qualitative study on experiences of MI with clients struggling with GAD, Marcus et al. (2011) found that MI increased client motivation to change. Beyond this general finding, however, client experiences were consistent with MI principles and processes: the therapist was experienced as empathic, MI provided a safe space to consider the possibility of change, and initial expectations were challenged. Clients were not told what do and found therapy more helpful than anticipated. Motivational Interviewing Integrated Into Other Psychotherapies for Anxiety According to Reichenberg and Seligman (2016), empirically supported interventions for anxiety disorders include CBT, behavioral therapy (desensitization, response prevention, and exposure), acceptance-based therapy, mindfulness-based CBT, problem solving, relaxation, and stress inoculation. Many of these treatments for anxiety require clients to do difficult work that require a high level of motivation (Westra & Aviram, 2015). For example, although quite effective in reducing phobias, exposure therapies, which require clients to directly face a feared object or situation, can be frightening to clients resulting in missed homework assignments or reduced engagement in therapy. Client motivation may wane in these circumstances, resulting in less-than-optimal treatment and poorer outcomes. Indeed, a common problem reported among CBT practitioners was treatment homework noncompliance (Helbig-Lang & Fehm, 2004). Cognitive-behavioral methods are the go-to approach to treating anxiety (Westra & Aviram, 2015). However, resistance to treatment can be a significant problem in CBT, limiting its effectiveness in assuaging anxiety symptoms (Westra & Norouzian, 2018). MI can be combined with exposure and other CBT-based therapies to enhance treatment compliance and follow-through for anxiety related problems. Muir et al. (2019) found that adding MI to CBT among a group of clients struggling with GAD improved markers of interpersonal change, including more assertiveness and less over accommodation. The authors also found evidence that resistance management, or rolling with resistance in MI parlance, was a conduit for effective interpersonal change. Similar findings by Aviram and Westra (2011) suggested that MI (four sessions) improved treatment outcomes when added prior to CBT for GAD, especially by

84 Applications of MI in CMH Settings lowering resistance and increasing client engagement with counseling. In another study, Peters et al. (2019) found that three sessions of MI used prior to CBT benefited people struggling with low functioning social anxiety disorder (SAD). However, the use of MI prior to CBT appeared to interfere with outcomes for those already high on readiness to change. As such, the use of MI combined with CBT seems effective for those lower in functioning and readiness to change, suggesting that MI is a key mechanism in lowering resistance. According to Muir et al. (2019), MI can be incorporated with CBT for anxiety-related problems in three primary ways. First, as with depression, MI spirit can serve as an underlying foundation throughout the CBT counseling process. Second, counselors can pivot to MI on an as needed basis, incorporating strategies when markers of resistance or ambivalence increase during the counseling process. MI also can be utilized as a standalone approach before turning to CBT. For example, in their research on integrating MI and CBT for GAD, Muir et al. utilized pure MI for four sessions to explore clients’ feelings about change. They followed these sessions with an integrated MI and CBT approach as outlined earlier. It appears from the empirical literature that a primary use of MI for treatment of anxiety is as a method to lower resistance and ambivalence about change. Anxiety can be quite distressing for individuals, and there can be considerable resistance to engage in counseling, especially with exposure methods. MI can ease some of this resistance by eliciting desire, abilities, reasons, and need for change, exploring and resolving ambivalence, and offering information (with permission) that may address inaccuracies the client may hold about treatment. Eating Disorders Eating disorders entail disturbances of feeding and eating behavior that can seriously compromise physical and mental health. Eating Disorders in the DSM 5 include anorexia nervosa, bulimia nervosa, binge eating disorder, and the less common pica and rumination disorder. Anorexia nervosa involves restricted energy intake, extremely low (and often dangerous) bodyweight, and an abnormal fear of gaining weight or looking fat. Compensatory behaviors, such as taking laxatives, excessive exercise, and vomiting, may or may not be a part of anorexia. Bulimia nervous involves binge eating and purging behavior, but without the low weight and fear of gaining weight symptoms as seen in anorexia. Compensatory behavior must be present for a bulimia nervosa diagnosis. The physical and psychological toll of eating disorders comes in the form of one or more of the following: poor nutrition, poorly absorbed nutrients, low body weight, anxiety, depression, and low self-esteem. Treatment for severe eating disorders typically entails specialized treatment facilities or separate treatment programs within established hospital settings. Because

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of the physical impact and nature of eating disorders, medical intervention/ supervision is often required, at least for initial stabilization. Once stabilized, clients can work on underlying psychological issues related to their eating problems. It is important to note that issues with eating extend far beyond what is in the DSM 5. According to the DSM (APA, 2013), eating disorders range from 0.5% (anorexia) to 3% (binge eating disorder). Much more prevalent is disordered eating, where clients may not meet full criteria for anorexia, bulimia, or binge eating disorder, but still struggle with many symptoms and complications related to eating behavior (Cassin & Geller, 2015). According to Cassin and Geller (2015), MI is an attractive option as a treatment for disordered eating. For example, it is well known that eating disorders resemble biopsychosocial processes like substance addiction. Because MI was born out of the addictions field, it would seem to be a natural fit for treating eating disorders. In addition, ambivalence, and low motivation to change can plague clients in eating disorder treatment programs, resulting in low retention and high dropout. As such, MI can be a useful approach to build motivation, resolve ambivalence, and ease resistance/discord (Cassin & Geller, 2015). Motivational Interviewing as a Stand-Alone Treatment for Eating Disorders MI can be used as a stand-alone approach to treating eating disorders, although it has been more commonly used in conjunction with other approaches. Few researchers have examined MI as the sole approach; in one study, Dunn et al. (2006) found that a single session of motivational enhancement prior to using a self-help manual increased readiness to change compared to self-help only among a sample of college students diagnosed with binge eating or bulimia nervosa disorders. The researchers, however, did not find any differences in eating attitudes and frequency between the groups. In a randomized controlled trial, Cassin et al. (2008) assigned 108 women with binge-eating disorder to either an adapted MI group (MI plus a self-help handbook) or a control (handbook only). Results indicated that the MI plus handbook group improved in confidence, mood, self-esteem, and general quality of life compared to the control. In addition, a greater proportion of women in the MI plus handbook group abstained from binge eating and no longer met full criteria for binge eating disorder. Clearly, these results are promising for using MI as a stand-alone method, but more research is needed, specifically research where MI is compared to another intervention (rather than a handbook; Cassin et al.). All elements of the MI process can be useful in working with eating disorders (Cassin et al., 2015). However, severity of symptoms, degree

86 Applications of MI in CMH Settings of ambivalence, level of intrinsic motivation, and volume of change talk dictate what elements of MI are more emphasized that others. Clients who present with eating disorders are rarely “ready to go” in terms of planning and action; often, there is considerable ambivalence to change, not so much about wanting to change their health and safety but wanting to change eating behaviors that serve valued functions (Cassin et al.). For example, individuals with anorexia nervosa may feel that their disordered eating gives them a sense of control (e.g., “you can’t make me eat”), makes them feel superior to others (e.g., “I am thinner than you”), and makes them feel “healthy” despite many (sometimes serious) health issues. As such, exploring ambivalence through the evoking process, eliciting change talk, and using the importance/confidence ruler can be useful strategies to help eating disorder clients process the change side of the ambivalence equation. Of course, some clients may be ready to change as evidenced by a quiet resolve and high motivation to feel better. In these instances, counselors should gently move from evoking to planning, where they can help clients navigate what a change plan might look like moving forward. From the limited research on using MI as a stand-alone approach to eating disorders, it appears that MI is necessary, but not sufficient, for helping clients with eating disorder symptoms. More research is needed, but the usefulness of MI with eating disorders appears to be in its ability to increase treatment retention and enhance readiness to change. This effect is important because readiness to change has been shown to be lower among clients starting eating disorder treatment (Cassin et al., 2015). In severe case of eating disorders, MI is probably not enough by itself, but can be a powerful adjunct to established treatment protocols, a topic we turn to next. Motivational Interviewing Integrated Into Other Psychotherapies for Eating Disorders In a systematic review of the literature (i.e., large-scale study that summarizes outcomes from multiple studies), Macdonald et al. (2012) examined the effectiveness of interventions that included strategies related to MI in the treatment of eating disorders. The authors concluded that interventions with an MI component showed promising results, especially related to increasing readiness and motivation to change. It appears that one of the best methods for incorporating MI in the treatment of eating disorders is to combine it with more established methods. For example, mental health counselors, knowing that readiness and motivation to change can be a challenge with this population, could intentionally incorporate MI for the first few sessions to “set the stage” for subsequent methods and care. This initial MI infusion is designed to lower resistance/discord, ease ambivalence, increase

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importance and confidence, and/or increase intrinsic motivation to change. We offer that beginning with MI also builds engagement and rapport. Although recommendations vary, using MI in this fashion for three to five sessions, before incorporating other approaches, appears to be adequate to address these early motivational issues. Evidenced-based treatments for eating disorders include CBT, including “third-wave” CBT methods (e.g., ACT, dialectical behavior therapy, mindfulness cognitive-behavior therapy), specific programs targeted to eating disorders, and family-based therapy (Reichenberg & Seligman, 2016). Family-based therapy has been found to be especially useful for children and adolescents struggling with eating disorders (Reichenberg & Seligman, 2016). MI can be a complementary “front-end” approach to any of these methods by assisting with readiness and strengthening motivation. Medication Compliance Issues and Motivational Interviewing Psychotropic medications, designed to ease psychological and behavioral symptoms, are a mainstay in today’s mental health agencies. According to Terlizzi and Zablotsky (2020), 15.8% (approximately one in seven) of Americans had taken prescription medications for their mental health issues. In addition, consider the astonishing fact that, in 2018, 161 million prescriptions were written for the top four medications in the United States (Zoloft, Xanax, Lexapro, and Desyrel; the top 25 prescriptions ran in the several hundred million in 2018; Psychcentral, 2019). In the CMH setting, medication can serve as the central treatment approach or in combination with counseling and psychotherapy. Indeed, evidence suggests that psychotropic medication can be effective in alleviating symptoms, especially if combined with counseling (Lewis & Culbreth, 2017). In the mental health counseling field, however, taking medication for psychiatric problems can be met with resistance, both from client and counselor perspectives. From the client’s perspective, medications may come with a host of unwanted side effects (just watch any advertisement for medication and pay attention to the list of risks/side effects at the end), and questions on their effectiveness. On the other hand, the dilemma for counselors is this: How do counselors integrate their developmental, nonmedical model philosophy of helping with the dominant medical model philosophy that mental disorders are caused by chemical imbalances in the brain? There is no easy answer to this question; however, Lewis and Culbreth (2017) suggested that it is important for mental health counselors to understand the role of medications in treating mental health concerns, serve as consultants/collaborators with psychiatrists, advocate for best treatment possible, and educate clients about the benefits and risks of using medication.

88 Applications of MI in CMH Settings Because of these resistances, medication noncompliance is a significant issue within the field of psychiatry. In a review of studies where researchers examined the issue, Balan et al. found rates of medication noncompliance to be between 40% and 50% across a range of mental health problems. Although it is difficult to pinpoint an exact reason, several possibilities have emerged in the literature: concerns about side effects, potential for addictions, ineffectiveness, and cultural prohibitions regarding mental health care (Balan et al., 2015). Aside from these issues, however, one must also consider the experiences of patients who undergo standard psychiatric care. A typical office visit includes a focus on the psychiatric history, listing of symptoms, information on medication, and proper dosing. They also tend to be brief, usually in the form of a 10–15-minute consultation (Carlat, 2010). We suggest that, whereas such a visit may be helpful for some, it may not generate the positive rapport and collaboration that would improve treatment compliance, but instead engender ambivalence, defensiveness, and poor doctor-patient relationships. Our intention is not to disparage psychiatrists who have an incredibly difficult job with often overwhelming caseloads. However, from our work with MI, a guiding style (rather than overly directive) can be incredibly useful in helping clients embrace treatment and maintain compliance. It may be the missing ingredient to standard psychiatric care that could bolster treatment compliance. In addition, use of brief MI (one 1-hour session) has been shown to be effective in helping clients with severe psychiatric conditions improve occupational outcomes compared to control (Hampson et al., 2015). Balan et al. (2015) provided an informative outline of typical motivational pharmacotherapy (MPT) sessions. All six steps may not be covered in one session; in these cases, the practitioner should continue working through the steps until a treatment plan is collaboratively agreed upon: 1. Welcome the patient. Affirm the patient’s desire to feel better and provide structure for the treatment and sessions. 2. Discuss the patient’s symptoms. Here the physician explores client symptoms and medication side effects. OARS is the foundational method, with lots of questions and reflections. If the client notes improvement, these are illuminated to encourage additional change talk. 3. Assess treatment compliance. Was the client able to be compliant with medication? If so, how was he or she able to do that? Focus on success to bolster self-efficacy. If there are barriers to taking medication, explore these and possible ways to overcome. 4. Use MI to elicit change talk (both preparatory and commitment language). Activities here can include developing discrepancies, exploring goals and values, and importance/confidence ruler exercises. 5. Resolve barriers to treatment. Exercises here could be listing and exploring common barriers to treatment adherence and exploring one's commitment to continue on the treatment plan.

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6. Review the treatment plan and medication. Work collaboratively regarding the treatment plan and strategies for moving forward. One possible barrier on the practitioner side is that psychiatrists or attending physicians may feel they do not have time to learn MI or incorporate these steps into their established practices. Mental health counselors, however, are in a perfect position to incorporate MPT! Although the ideal scenario would be that the attending physician incorporate MI, a viable alternative would be to farm out discussions regarding compliance to mental health counselors who work alongside psychiatrists in CMH agencies. Mental health counselors could competently work through steps 1–5 above (if they are trained in MI), where step 6 could be collaborative between psychiatrist, mental health counselor, and client. Indeed, in an MI-based approach using anti-depressant medications (motivational enhancement therapy for antidepressants; META), Interian et al. (2013) utilized one clinical psychologist and three psychology doctoral students to provide MI within the research study. Results indicated that META showed feasibility and promising effects for antidepressant compliance among a sample of Latino participants. Well-trained therapists could be an important component to medication compliance issues. To recap, the use of MI in the treatment of common problems within CMH agencies falls into three strategies. First, MI serves as a backdrop, the metaphorical canvas from which other approaches can be “painted” on. This backdrop includes MI spirit and the basic OARS skills, which by themselves lower discord and avoid traps that engender resistance to change. Second, MI can be incorporated first, before other methods are implemented. This has the advantage of addressing motivational issues that may sabotage therapy success. Third, MI can be incorporated on an “as needed” basis; motivation is not a static concept but tends to ebb and flow as clients navigate their motivation, ambivalence, and resistance. Falling back on MI when motivation ebbs can be a useful strategy to help the client get back on track. Let us now to turn to a case study to illustrate using MI with the common clinical issue of anxiety.

Case Study We now turn to the case of Sharon, who struggles with GAD. Sharon describes her anxiety and tension in as a vague sense of trepidation, where she finds it difficult to control her worry. When asked if there was anything specific that she worries about aside from typical everyday worries (such as children’s safety and being on time), she could not put her finger on anything tangible. Although she has functioned reasonably well throughout the day, lately she has found it increasingly difficult to concentrate. Her general tension also tends to interfere with sleep. She has lost focus at work, which has led to some

90 Applications of MI in CMH Settings unpleasant interactions with her boss. She worries that she is starting to avoid activities she used to enjoy because the constant worry is an unpleasant distraction. The case study picks up in the early part of Sharon’s counseling, where MI can be most useful. Although the go-to method for GAD is CBT, Sharon feels some resistance to engage in the counseling process. Knowing that these techniques have helped many clients, the counselor uses MI to work with her initial ambivalence. COUNSELOR: Hello Sharon, welcome back and it’s nice to see you again. SHARON: Hello. Nice to see you, too. COUNSELOR: If you recall from last week, we discussed a treatment plan

to help with your anxiety struggles. You had some hesitations about whether cognitive behavioral therapy would work. SHARON: Ya, I am just not too sure something like that can help. COUNSELOR: You’re wondering whether this approach can help ease the anxiety that you have experienced a long time! (Simple reflection). SHARON: It’s difficult for me to see how changing my thoughts will help my anxiety. I have tried to think more positively before, and it just doesn’t seem to help. COUNSELOR: You have tried some thinking strategies on your own, but they didn’t seem to get you where you want to be. (Simple reflection) SHARON: I mean, I understand the theory behind the approach, and maybe it can be effective, it’s just I don’t have a lot of confidence I can get better. COUNSELOR: And so why spend all this time and money on something that may or may not work. (Complex Reflection). SHARON: Exactly! COUNSELOR: Would it be alright at this point if I provide a little more information about CBT and what you might expect? (Providing information with permission) SHARON: Sure, I am open to hearing about it, because the anxiety has gotten worse, and that is why I am here. COUNSELOR: Ok, great. So, CBT is the standard of care for generalized anxiety disorder, and many clients have been helped by practicing in session and using homework techniques at home. It really is more than just “thinking positive,” but rather a comprehensive approach to address thinking errors that lead to anxious feelings. What do you make of that? (Providing information and then checking in with the client) SHARON: Hmm. I guess I never thought of it like that .  .  . how our thoughts, or thinking errors lead to difficult feelings. I would like to learn more. COUNSELOR: That is new information about CBT that has you intrigued. (Simple reflection). SHARON: Yes.

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On a scale of 1–10, with 1 being “not interested in treatment” and 10 being “very interested in treatment,” where would you place yourself now? (Open scaling question designed to explore and increase importance). SHARON: Before I came in I would say probably a 4, but now I’m up to a 7. COUNSELOR: And, what makes it a 7 and not a 5? (Follow-up scaling question) SHARON: Well, the idea that many clients have been helped with CBT for my type of anxiety, and the potential to find my thinking errors and do something about them makes it important to me. COUNSELOR: Some of the information provided today has shifted your thoughts about treatment. (Simple reflection). SHARON: Well, I am certainly more open to the possibilities now. COUNSELOR: You said you were at a “7.” What would it take to tick that up a bit to, say, an “8” or “9”? (Follow-up scaling question) SHARON: I think I would need to see some initial successes. If I start to feel better, then it will be more important to participate in counseling and go 100%. COUNSELOR: Before you invest time and money, you want to see some benefit and make sure treatment is a fit for you. SHARON: That’s right, but I feel right now that I am ready. Let’s talk more about the plan and go from there. COUNSELOR:

In this case study, Sharon presents with initial resistance to CBT treatment for GAD. It is not uncommon for clients struggling with anxiety to resist treatment for any number of reasons. In this case, Sharon did not have confidence that it would work. She tried some self-help strategies at home, and they were not very effective. She wanted more information on the treatment before diving in with her time and money. She needs to see some initial success before doing making a commitment. Using a non-MI response, the counselor could have lectured Sharon about CBT, dismissed her concerns, and provided immediate homework. With Sharon, the outcome would be predictable; she would most likely avoid the homework, provide limited effort in session, and perhaps even drop out of treatment altogether. The counselor approached her from and MI perspective, offered copious reflective statements, used open questions, and genuinely wanted to hear her perspective. Toward the end, Sharon not only was open to treatment but wanted to start a plan with the counselor. Using MI as a precursor to other forms of treatment can be an effective measure to increase treatment engagement, improve retention, and encourage successful outcomes.

Summary The CMH setting offers many opportunities to apply MI in the treatment of common clinical problems. This chapter focused on four common

92 Applications of MI in CMH Settings presenting problems: depressive disorders, anxiety disorders, eating disorders, and medication compliance issues. MI can be utilized as a stand-alone approach or in combination with other approaches, such as CBT, for each presenting problem. MI has been shown to be an effective way to begin the counseling process with clients struggling with DSM 5 disorders, primarily by building rapport and lowering resistance/discord. However, although MI also can be used throughout the counseling process, it may not be enough for moderate or severe clinical cases. Activities and Resources 1. As noted in this chapter, a common way to utilize MI with various mental health disorders is to begin the treatment with MI, followed by other approaches as motivation increases. The following activity can be done among clinical treatment teams or in classroom settings and is designed to develop a feel for MI versus other approaches. Pair up into triads where one role plays the counselor, one role plays the client, and the other role plays the observer. The client should role play an anxiety or mood disorder. The counselor starts off with MI and then, after three to five minutes, intentionally switches to CBT or some other therapeutic approach. After using the therapeutic approach, the counselor switches back to MI. This switching back and forth occurs for a few rounds. The idea is to help develop a feel for MI and transitioning to another approach. What reaction did you receive from the client as you switched approaches? Observers can play an important role in this exercise as they can provide insights that the counselor or client may have missed. 2. Pick a mental disorder from the DSM 5 that was not covered in this chapter. Explore how MI might be useful with that disorder. What elements of MI would be most useful? Least useful? Would MI be effective as a starting off point, then moving on to other approaches? Or is there another way that MI could be incorporated? 3. For an excellent reference and comprehensive review of MI across a wide range of presenting clinical problems, consult Arkowitz, Miller, and Rollnick (2015). Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford.

Note 1. MET is considered a “structured form” of MI. It is usually manualized, brief in nature, and incorporates assessment feedback as part of the process.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). APA.

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Arkowitz, H., Miller, W. R., & Rollnick, S. (2015). Conclusions and future directions. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Aviram, A., & Westra, H. A. (2011). The impact of motivational interviewing on resistance in cognitive behavioural therapy for generalized anxiety disorder. Psychotherapy Research, 21, 698–708. Balan, I. C., Moyers, T. B., & Lewis-Fernandez, R. (2015). Motivational pharmacotherapy: Combining motivational interviewing and antidepressant therapy to improve treatment outcomes. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Britton, P. C. (2015). Motivational interviewing to address suicidal ideation. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Burke, B. L. (2011). What can motivational interviewing do for you? Cognitive and Behavioral Practice, 18, 74–81. Carlat, D. J. (2010). Unhinged: The trouble with psychiatry—A doctor’s revelations about a profession in crisis. Free Press. Cassin, S. E., & Geller, J. (2015). Motivational interviewing in the treatment of disordered eating. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Cassin, S. E., von Ranson, K. M., Heng, K., Brar, J., & Wojtowicz, A. E. (2008). Adapted motivational interviewing for women with binge eating disorder: A randomized control trial. Psychology of Addictive Behaviors, 22, 417–425. Dunn, E. C., Neighbors, C., & Larimer, M. E. (2006). Motivational enhancement therapy and self-help treatment for binge eaters. Psychology of Addictive Behaviors, 20, 44–52. Hampson, M. E., Hicks, R. E., & Watt, B. D. (2015). Exploring the effectiveness of motivational interviewing in re-engaging people diagnosed with severe psychiatric conditions at work, study, or community participation. American Journal of Psychiatric Rehabilitation, 18, 265–279. Helbig-Lang, S., & Fehm, L. (2004). Problems with homework in CBT: Rare exception or rather frequent? Journal of Behavioural and Cognitive Psychotherapy, 32, 291–301. Interian, A., Lewis-Fernandez, R., Gara, M. A., & Escobar, J. I. (2013). A randomized-controlled trial of an intervention to improve antidepressant adherence among Latinos with depression. Depression and Anxiety, 30, 688–696. Korte, K. J., & Schmidt, N. B. (2013). Motivational enhancement therapy reduces anxiety sensitivity. Cognitive Therapy Research, 37, 1140–1150. Lewis, T. F., & Culbreth, J. (2017). Psychiatry and psychopharmacology. In J. S. Young & C. S. Cashwell (Eds.), Clinical mental health counseling: Elements of effective practice. Sage. Macdonald, P., Hibbs, R., Corfield, F., & Treasure, J. (2012). The use of motivational interviewing in eating disorders: A systematic review. Psychiatry Research, 200, 1–11. Marcus, M., Westra, H., Agnus, L., & Kertes, A. (2011). Client experiences of motivational interviewing for generalized anxiety disorder: A qualitative analysis. Psychotherapy Research, 21, 447–461.

94 Applications of MI in CMH Settings Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). Guilford. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford. Muir, H. J., Constantino, M. J., Coyne, A. E., Westra, H. A., & Antony, M. M. (2019). Integrating responsive motivational interviewing with cognitive-behavioral therapy for generalized anxiety disorder: Direct and Indirect effects on Interpersonal outcomes. Journal of Psychotherapy Integration, 31, 54–69. Naar, S., & Flynn, H. (2015). Motivational interviewing and the treatment of depression. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Perez, P. J. (2005). Treatment setting and treatment planning. In P. Stevens & R. L. Smith (Eds.), Substance abuse counseling: Theory and practice (2nd ed.). Upper Saddle River. Peters, L., Romano, M., Byrow, Y., Gregory, B., Mclellan, L. F., Brockveld, K., Baillie, A., Gaston, J., & Rapee, R. M. (2019). Motivational interviewing prior to cognitive behavioural treatment for social anxiety disorder: A randomised controlled trial. Journal of Affective Disorders, 256, 70–78. Psychcentral (2019). Top 25 psychiatric medications for 2018. PsychCentral. Available: Top 25 Psychiatric Medications for 2018 (psychcentral.com). Reichenberg, L. W., & Seligman, L. (2016). Selecting effective treatments: A Comprehensive, systematic guide to treating mental disorders (5th ed.). Wiley. Rollnick, S. (2010). Motivational interviewing for mental health disorders. PESI Continuing Education Seminars. Rollnick, S., Miller, W. R., & Butler, C. (2008). Motivational interviewing in health care: Helping patients change behavior. Guilford. Secades-Villa, R., Fernande-Herminda, J. R., & Arnaez-Montaraz, C. (2004). Motivational interviewing and treatment retention among drug user patients: A pilot study. Substance Use & Misuse, 39, 1369–1378. Terlizzi, E. P., & Zablotsky, B. (2020). Mental health treatment among adults: United States, 2019. NCHS Data Brief, no 380. Hyattsville, MD: National Center for Health Statistics. Westra, H. A. (2012). Motivational interviewing in the treatment of anxiety. Guilford. Westra, H. A., & Aviram, A. (2015). Motivational interviewing and the treatment of depression. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Westra, H. A., & Norouzian, N. (2018). Using motivational interviewing to manage process markers of ambivalence and resistance in cognitive behavioral therapy. Cognitive Therapy Research, 42, 193–203. Yusko, D., Drapkin, M. L., & Yeh, R. (2015). Enhancing motivation in individuals with posttraumatic stress disorder and comorbid substance use disorders. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford.

6

Motivational Interviewing and Group Counseling

Introduction Group therapy has a rich history as a legitimate treatment modality proven effective across a wide swath of mental health problems (Sobell & Sobell, 2011; Yalom & Leszcz, 2005), including substance use (Sobell  & Sobell, 2011), anxiety (Fawcett et al., 2020), depression (Fawcett et al.), trauma (Katz, 2016), and psychosis (Owen et al., 2015). In the past several years, there has been growing interest in the application of MI, originally conceptualized as an individual approach, in the group therapy delivery format. In many ways, MI is used to enhance already established group practices (e.g., CBT addictions groups; Sobell & Sobell, 2011). The blending of group theory and practice with the philosophy and skills of MI can provide a powerful mix for group leaders. For example, groups with depressed clients might include information, psychoeducation, and skillbuilding exercises. Whereas these elements are important, little change is likely to come about from these group experiences without explorations of ambivalence, motivation, and plans for change. In addition, Foote et al. (1999) found that key motivational processes are impacted by group motivational interviewing. For example, clients in their study were found to perceive the group MI environment and group leader as significantly more supportive of client autonomy than treatment as usual. Autonomy supportive counseling, such as MI, is theorized to lead to greater intrinsic motivation to change. That is, motivation that comes from internal resources, rather than external rewards. Although both types of motivation can be important in change, MI emphasizes increasing the more enduring and personally satisfying intrinsic type of motivation. In this chapter, we provide an overview of the group counseling process, focusing on the classic stages of group therapy and the “therapeutic factors” of group therapy proposed by Yalom in his classic text, “The Theory and Practice of Group Psychotherapy.” Although a thorough analysis of group process and practice is beyond the scope of discussion here, we hope a basic overview of group process will be a foundation for how MI can be incorporated into groups. We then explore the application of DOI: 10.4324/9781351244596-8

96 Applications of MI in CMH Settings MI in group counseling settings, with a focus on the standard outpatient group that is part of typical services offered by community mental health agencies. Emphasis will be placed on practical strategies and empirical support as available. A case study to illustrate MI used in a group setting, as well as common activities and resources, will conclude the chapter.

Overview of Group Counseling Process In the field of mental health counseling, group process and practices are a central tenet to training mental health counselors. Indeed, according to the Council for Accreditation for Counseling and Related Educational programs (CACREP), counselor education programs must train students in group counseling and group work as part of the counseling curriculum to meet standards for accreditation (2016 CACREP standards, 2.F.6.a-h). Key components of counselor training include the theoretical foundations of group work, dynamics associated with group process, and therapeutic factors and their role in effectiveness. In general, there are two forms of group counseling: inpatient and outpatient. Inpatient groups are generally open groups in which the composition can change from day to day. For example, in a hospital psychiatric unit, counselors may see clients in crisis who stay anywhere from four to seven days. Rapid turnover necessitates group strategies designed to be impactful for single group sessions. Although clients can certainly have longer stays in inpatient settings, the typical scenario is detox and/ or stabilization, and then referral to other forms of care (e.g., intensive outpatient programs). Outpatient groups allow clients to live at home, go to work, and keep a regular schedule (Brooks & McHenry, 2015). They occur one to several times a week and generally last 90 minutes (although some may be as long as three hours). With outpatient groups, the group leader needs to be aware that clients leave the group setting to return to their normal lives. Processing how clients are feeling after the group is important to ensure they navigate potential issues and triggers once they leave group. At first glance, one may assume that MI is most effective with outpatient groups. We generally agree with this assumption. Clients in outpatient groups are generally better functioning, and thus can grasp nuances in motivation, resistance, and the change process to a greater degree. The outpatient setting allows for group development and consistent topics week in and week out. The processes of group MI, reviewed below, can play out more consistently with groups that meet over time. With that being said, we also believe that MI can be effective with inpatient group settings. Although counselors may not have the time to carry out a full MI protocol (because clients change so often), elements of MI can still be utilized as one session interventions. For example, helping clients to assess the importance of change, exploring goals and

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values, exploring the pros and cons of change, and looking at best case/ worst outcomes of current behavior would all be useful foci for single group sessions. In this chapter, we “lean” toward the outpatient group in our examples and discussions; however, the reader will readily see the usefulness of MI in inpatient settings as the empirical literature bears out. Stages of Group Therapy As with any organization with diverse individuals, group therapy usually progresses in developmental stages (Young, 2012). One of the bestknown models for group development was proposed by Tuckman and Jensen (1977). Their hierarchical and sequential model is characterized by five stages: (a) forming, (b) storming, (c) norming, and (d) performing (the fifth stage is adjourning, which we will not cover below). The forming stage is characterized by ambivalence, uncertainty, and confusing about the purpose of the group (Young, 2012). As such, group members will rely heavily on the group leaders for direction and modeling how to interact within the group. This also is an appropriate time for group leaders to build rapport, cohesion, and trust within the group. As trust begins to build, group leaders are tasked with helping group members create personal goals. The OARS skills are important in this stage of group therapy. In addition, MI spirit is emphasized to promote engagement, the first process of MI. The storming stage is characterized by confrontation, resistance, and emotionally charged interactions among group members (Young, 2012). Some members may feel resentment or even hostility toward other members. Group leaders may feel challenged by individual members or subgroups as they try to gain influence and power over the leader and other group members. Many of the strategies for addressing resistance (discord) in individual MI are useful for group counseling during this stage. The next stage, norming, is characterized by easing of resistances as members begin to enhance trust and openly express ideas, viewpoints, suggestions, and opinions. Members begin to accept each other as companions on the road of life, each with his or her own unique (but also similar) struggles. Group harmony and preservation take precedence over conflict. Within this stage, MI strategies include linking group members with common experiences, elaborating and reflecting change talk, building confidence through vicarious learning, and helping members support each other. The performing stage encompasses productive collaboration on underlying issues and difficulties. Support from other members is ongoing and strong. Interactions are positive and constructive, with the goal of helping each other resolve inner conflicts or other issues that arise. From an

98 Applications of MI in CMH Settings MI perspective, this final stage may include strengthening confidence and planning strategies. Although there are well over 100 models of group development (Young, 2013), Tuckman and Jensen’s (1977) developmental model provides a roadmap for group clinicians seeking to understand the normal developmental processes of the small group and, as we will show, align nicely with MI group processes. Regardless of model, most stages of a group proceed through beginning issues (e.g., resistance) to advanced functioning (e.g., support, collaboration; Tuckman & Jensen, 1977; Yalom & Leszcz, 2020). Indeed, all groups experience beginning apprehension, discord, increased productivity, interpersonal connection, inconsistency, and termination. It is important to keep in mind that, as with any stage approach, groups rarely develop in a linear fashion; rather, groups can and do move back and forth between stages depending on group membership, type of group, and leader skill. A group also may straddle between two stages. Let us now examine the factors and processes that make group therapy such an effective mode of counseling. Therapeutic Factors There cannot be a discussion of group therapy without mentioning the 11 “therapeutic factors,” first espoused by Yalom in his classic text, the Theory and Practice of Group Psychotherapy. Many of the factors can be realized in individual counseling; however, they are enhanced within the group context due to its very nature. That is, the support, empathy, feedback, challenge, and courage from others who are struggling with similar life problems are powerful healing mechanisms. Many therapeutic factors, such as instillation of hope, imparting information, and altruism, align nicely with the spirit and approach of MI. Instillation of Hope Hope is a crucially important therapeutic factor within group therapy. According to Yalom and Leszcz (2020), hope and faith in the therapeutic process can itself be effective. Indeed, group counselors can go a long way in helping clients increase their belief and confidence that this therapeutic format will help them resolve their struggles (Yalom & Leszcz, 2020). Even though group members may be along different ends of the change process, providing positive expectations, conveying optimism, and reinforcing small gains can go a long way in strengthening this therapeutic factor. Universality Universality implies that all humans struggle, and when group members learn that other members’ challenges are like theirs, they report being

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more in touch with the world (Yalom & Leszcz, 2020). Often, selfdisclosure within a group format can bring relief at discovering that they are not alone and that others share the same experiences and difficulties (Yalom & Leszcz, 2020). The task of the group counselor is to focus on bridging client experiences so that group members can see the universality in the dilemmas they face. Imparting Information Providing content, advice, suggestions, and direct guidance can come from counselors or group members, and often fills gaps in knowledge or corrects misinformation that clients might hold. Of course, many clients come to counseling expecting to receive information that will help them feel better, make better choices, and live more in line with their values and goals. Imparting information in an MI-consistent way can instill confidence within clients about how to move forward to overcome life struggles. Altruism Healing in counseling groups not only comes from receiving help, but also giving to others. Yalom and Leszcz (2020) pointed out that group members in psychiatric groups often feel they have nothing meaningful to offer; group counseling is unique in that members are given opportunity to benefit and help others. It is in the act of giving where group members feel a sense of meaning and connection with other group members, which improves self-worth and self-esteem. Group counselors can illuminate altruistic acts of members to highlight this therapeutic factor. In addition, at its core, altruism encompasses many of the components of MI spirit. Corrective Recapitulation of the Primary Family Group Individuals in group counseling most likely come from highly unsatisfactory early family relationships. Indeed, one of the reasons they may be in group counseling is because of unfinished business from these early relationships and patterns. The counseling group resembles the primary family unit, with authoritarian figures, sibling figures, sharing of deep emotion, and competitive/hostile feelings that are bound to happen, just like within one’s early family environment (Yalom & Leszcz, 2020). As such, the group provides a venue for members to relive some of these experiences. Transference is common in that group members may be triggered or reactive emotionally to another member. According to Yalom and Leszcz, the reliving of these early experiences is encouraged; however, they must be relived correctively. Fixed rules and roles, housed in early experiences, must be constantly challenged, and explored, with

100 Applications of MI in CMH Settings investigations into new behaviors and ways of being firmly established. With the support of the group counselor and other members, clients can make changes in an atmosphere of support and empathy, something that was probably missing in their early years. Socializing Techniques The development of social skills occurs in any group counseling format, and the group is uniquely positioned to help clients develop and hone their social skills. Groups allow for immediate interpersonal feedback that can help clients be more aware of their patterns of interaction. For example, a client may not make eye contact when talking to others, or share information in a vague, hard-to-understand manner. Poor social skills may be undermining their social relationships. Group counselors are well positioned to help clients become aware of their social patterns and encourage other members to give feedback when appropriate. Imitative Behavior Group counseling offers members a chance to imitate others who have been successful at changing behavior. From an MI perspective, this observational learning process increases confidence toward change. That is, witnessing others try new behaviors with a successful outcome can be motivating as clients try to imitate their behavior. Imitative behavior allows clients to “try on” certain skills or attitudes and see what fits and what does not fit. Determining what does not fit also should be therapeutic progress. Interpersonal Learning Interpersonal learning is a central part of the group counseling process. The fundamental idea is that psychological symptoms emanate from interpersonal problems. As noted earlier, the group is uniquely positioned to help members identify relational patterns, assess their usefulness, and make changes consummate with their therapy goals. These processes occur through peer and counselor feedback and self-observation. Once healthier adaptations in interpersonal relationships are made within the group, confidence increases to try new interpersonal behaviors outside of the group. Yalom and Leszcz (2020) likened the psychotherapy group as a social microcosm, where members “will interact with the other members of the group just as they interact with other people in their social sphere . . .” (p. 50). As such, group counselors can see firsthand each members’ interpersonal dynamics because they tend to replay these within the social microcosm of the group. This makes the counseling group fertile ground for interpersonal awareness and change.

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Group Cohesion Group cohesion, and its importance, is considered the analogue to the therapeutic relationship in individual counseling (Yalom & Leszcz, 2020). However, as Yalom and Leszcz (2020) noted, the “relationship” in group counseling must be broader, encompassing the group members’ relationship with the therapist, with each other, and the group. The importance of strong group cohesion cannot be overstated and is critical in successful group outcomes (Yalom & Leszcz, 2020). Members of a cohesive group show more acceptance, support, understanding, and are more willing to explore genuine feelings with other members and the group leader (Yalom & Leszcz, 2020). Catharsis Another important process in group therapy is catharsis, or the discharge or “letting go” of pent-up feelings and negative emotions. Usually, catharsis is in the form of emotional expression from one person to another (or from one person about another) or expressing frustrations with some experience. Research has shown that whereas catharsis in group therapy is important, it is not enough to enact change (Yalom & Leszcz, 2020). Catharsis can be especially powerful, however, when strong bonds between the group members have formed (Yalom & Leszcz, 2020). Getting things off one’s chest before sufficient group cohesion may be too intense for some group members. The skilled group therapist recognizes this fact and is deliberative when guiding clients toward catharsis. Existential Factors The final therapeutic factor in group therapy includes issues that have to do with the human condition, such as responsibility, will, isolation, and meaning. Many group members struggle directly with existential concerns or find one or more critically important in their lives. Meaning is a good example. The topic of meaning invariable strikes a chord with clients. Realizing that one is the author or meaning maker of his or her life engenders anxiety but also possibility. Universality is an important factor that nicely aligns with existential concerns. It is comforting to realize that whereas we are all in this (life) together, each of us has the shared experience of ultimately facing the ultimate concerns of existence. These 11 therapeutic factors serve as the healing elements of effective group counseling. We say “healing” in the sense that groups that manifest each of these factors will find steady progress as members learn to let go of destructive patterns, learn new coping skills, and gain insights into their own growth. With the stages of group counseling and therapeutic factors serving as a foundation to the group counseling process, we now

102 Applications of MI in CMH Settings turn to ways group leaders within mental health agencies can incorporate MI in their group counseling practice.

Incorporating Motivational Interviewing into Group Counseling Practice Individual Versus Group Motivational Interviewing With the explosion of supportive research and the use of MI in clinical practice, we noticed in our trainings that the question inevitably came up: Can MI be utilized in groups? When I (TFL) first thought about this question, I was not sure. I did not see clearly how MI, designed to help individuals change, could be applied in a group setting. After all, motivation is an individual phenomenon, and clients present with different stages of change that require different interventions. Client goals are unique with each having differing levels of importance and confidence about change. However, as research and conceptualization of MI in groups developed, my views on MI in groups began to change and, with some flexibility in technique and terminology, it turns out that MI can be a viable option for group counseling practice. To run a successful MI group, counselors should be well versed in the principles, spirit, processes, and skills of MI (Krejci, & Neugebauer, 2015). Group skills also are needed to manage interactions, focus on individual needs without losing sight of group process, and encourage group members to adopt their own set of MI skills (e.g., OARS) so they can help each other (Velasquez et al., 2006). There may be times throughout the group process that require greater emphasis on MI than generic group skills and vice versa. Rather than worrying about the one right way to “do” MI in groups, we advocate that counselors fall back on their MI and groups skills, with the intention of helping group members approach change in a positive manner. In the sections that follow, we will look at the four processes of the MI group, which correspond to the four processes of individual MI (engaging, focusing, evoking, planning). It is our hope that after reading this section, the reader can better understand MI as applied to group counseling. Leading Motivational Interviewing Groups Wagner and Ingersoll (2013) proposed several principles for leading MI groups. These principles generally overlap with individual MI and can be contrasted with other forms of group counseling; consider these principles as what sets MI groups apart from other types of groups. The principles include (a) focus on the positives, (b) bring group members into the moment, (c) explore perspectives and focus on the present, (d) hear complaints but do not elicit grievances, (e) broaden perspectives and focus on the future, (f) reflect and explore positive focus on desire, needs, plans, and self, (g)

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support self-efficacy, and (h) counteract any negative reactions before sessions end (p. 59). Let us take a brief look at some of the more relevant (to MI) principles below (specifically a, d, f, and g); the reader may wish to consult Wagner and Ingersoll for descriptions of all these principles and phases. Focus on Positives MI group leaders focus on strengths, past successes, and what is working more than disability, disease, or deficit. Of course, focusing on the positives is squarely in line with the spirit of MI. MI leaders also do not place emphasis on catharsis as part of the group process, although this may be an important component to other groups (Wagner & Ingersoll, 2013). The positive energy generated in MI groups is directed toward helping clients change. Hear Complaints, But Do Not Elicit Grievances This principle is analogous to a key practice in MI: rolling with resistance (or discord; Miller & Rollnick, 2013). In MI groups, the emphasis is on the present and making positive changes in one’s life. Naturally, when a group begins, there are going to be complaints, discord, resistances, and so forth. The task of the MI group leader is to acknowledge these difficulties and try to shift focus to what positives the group members can focus on moving forward (Wagner & Ingersoll, 2013). Reflect and Explore Positive Focus on Desire, Needs, Plans, and Self A focus on desire for change, need for change, planning, and self-improvement comprises essential components of motivation. In individual MI, these foci are strategically emphasized to elicit change talk. For example, asking a client why they want to change elicits change talk focused on desire (I want to change because I will feel better if I get my health back). In group settings, leaders encourage group members to reflect and explore their desires and need for changing, as well as how group members might plan for change. This exploration stays positive as much as possible; even within trying times, clients can still find some encouragement in their lives. Unfortunately, discussions can easily take a negative turn within group settings, where clients might not find any desire to change and see their situations as hopeless. It is important in these situations for group leaders to acknowledge and reflect feelings and frustrations, and then shift focus by pulling out positive examples from others (Wagner & Ingersoll, 2013). Support Self-Efficacy Miller and Rollnick (1991) discussed self-efficacy as an important principle in individual MI. Self-efficacy refers to one’s belief that he or she

104 Applications of MI in CMH Settings can overcome obstacles and accomplish goals (Bandura, 1977) and is loosely aligned with confidence. Self-efficacy (believing one can overcome and accomplish a goal) and confidence (the feeling that one can accomplish a goal) are important components for motivation because they address the issue of “how” to change. As with individual MI, group MI leaders strive to support self-efficacy at every turn. Group members may struggle with finding the inner resources to navigate difficult terrain; supporting self-efficacy helps them find those resources, point them out, and encourage movement toward change. The beauty of group counseling is that if one member struggles with self-efficacy, there are probably others. The group, with careful guidance by the MI group leader, becomes a safe place where members can learn and grow from each other. Indeed, self-efficacy can be enhanced by observing how others were able to overcome difficulties, processing those experiences, and reflecting on how strategies may apply to other member’s lives or situations. These principles are infused throughout the MI group process. As with individual MI, there are four phases within MI groups. These phases include engaging the group, exploring perspectives, broadening perspectives, and moving to action (Berg, 2015). We explore each of these in turn below. Engaging the Group In individual MI practice, counselors use the spirit of MI and OARS to establish rapport and fulfill the first process of MI: engaging. The analog process in groups also is engagement, with the obvious difference of having to engage with several members instead of one. Engaging a group entails the strategic use of OARS as members introduce themselves and begin discussing their struggles. It also entails emphasizing collaboration and stressing how the group will work together in an atmosphere of respect and partnership (Velasquez et al., 2006). Because group counseling entails a collection of several individuals working on similar (or different) problems, there are bound to be interpersonal issues of which the group leaders need to be aware. The goal of the group leader is to balance the need for individual expression while minimizing potential group disruption from members who tend to dominate or otherwise sabotage group progress. An effective way to engage the group is to promote a group attitude of empathy, support, and regard (Velasquez et al., 2006). Another effective way to engage group members is to focus on individual concerns while also linking member experiences to each other (Berg, 2015). Engagement, then, happens when both individual members feel heard through basic MI skills, and then feel connected to others who may be experiencing similar feelings.

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Exploring Perspectives As with individual MI, engaging the group may take one or several sessions. How does a group leader determine when to move on to the next phase of group MI? Usually, a strongly engaged group will have a “flow” to it with minimal resistance or discord. Early conflicts or disagreements are understood or resolved, and the group starts to indicate it is time to move on. Exploring perspectives invites clients to see the wider picture by exploring their values, goals, ambivalence, and lifestyle (Wagner & Ingersoll, 2013). The guiding principles in this phase includes expressing empathy, focusing on the positives, bringing the group into the present moment, focusing on the present, and acknowledge suffering, but not evoking grievances (Wagner & Ingersoll). The final principle needs a little elaboration. MI practitioners typically do not help clients explore their suffering at a deeper level, but rather acknowledge one’s suffering by turning the focus to how one can move forward. As applied to group, this principle helps group counselors avoid the trap of focusing too much on one member’s grievances, which can bias their own perceptions and block possibilities for change. Often, simply sharing one’s struggles with others can be enough to pave the way for a path forward (Wagner & Ingersoll, 2013). Specific MI strategies during this phase entail exploring lifestyles, introducing and exploring ambivalence, and clarifying/exploring values (Wagner & Ingersoll, 2013; Berg, 2015). Exploring lifestyles invites group members to delve into and share how they live in a “typical day,” what they do, and to whom they typically interact (Wagner & Ingersoll, 2013). Another strategy is to highlight maladaptive habits getting in the way of progress, usually through the skill of developing discrepancies.

Broadening Perspectives The group process necessitates that as time in the group increases, participants turn more of their attention to each other rather than strictly to the counselor (Berg, 2015). Connections build, and members become more open sharing statements or taking in ideas from others that might improve their lives. When the group leader observes this shift in the group dynamic, the group has most likely moved to the next phase of MI groups: broadening perspectives (Wagner & Ingersoll, 2013). In the broadening perspectives phase, group members expand awareness by opening themselves up to possibilities as they share problems, coping strategies, and different viewpoints. The universality of suffering helps members put their problems into perspective, as suddenly current issues do not seem as daunting or intractable. According to Wagner and Ingersoll (2013), guiding principles for the broadening perspectives phase include (a) focusing on the positives, (b) focus on the future, (c) developing discrepancies, and (d) accepting defensiveness (p. 200).

106 Applications of MI in CMH Settings Focusing on the positive is foundational to MI and extends from earlier phases. Group leaders promote a positive environment that counters negative dialogue and prevents negative emotions from spiraling downward. This is not to say that negative feelings should never be explored; however, in this phase we want to broaden or expand clients’ viewpoints and to instill hope in the possibility of positive change. Over-emphasis on negative feelings tend to narrow one’s focus and attention. Staying positive promotes creativity (Berg, 2015), diverts more energy to what is working (or may work), communicates encouragement, and expands resources and hope. A common method in MI to stay positive is the shifting focus strategy. For example, a group member may lament over whether he is a “borderline.”An MI group leader can shift focus away from such labels, which lead to unnecessary and unproductive debate, and toward positive behaviors, recent successes, and feedback the client can take from the group. The principle of focusing on the future encourages members to create a positive vision of how they want their life to unfold. Although there is value to discussing and exploring past and current circumstances, imagining possibilities opens goals and avenues toward those goals, and this is where MI group leaders want to explore (Wagner & Ingersoll, 2013). Developing discrepancies is a classic MI exercise where counselors intentionally illuminate discrepancies between clients’ stated goals and values and their current behavior. This strategy was described in detail in Chapter 1 and will not be reviewed in depth here. According to Wagner and Ingersoll (2013), developing discrepancies can be an even more powerful technique in the group setting. If you recall from Chapter 1, developing discrepancies creates cognitive discomfort in the client’s life, where goals and values are not aligned with behaviors. In the group setting, support from other members can energize and motivate clients to consider other possibilities for changing behavior and/or goals (Wagner & Ingersoll). The group also allows for vicarious learning as all members work through their own discrepancies. For example, if a client is struggling with how to change a behavior to better match stated goals, he can learn from other members with similar difficulties and how they overcame their challenges. Accepting defensiveness is the final principle of the broadening perspectives phase (Berge, 2015). Here group leaders are aware of possible discord that can occur during times of increased sharing. As group members broaden their conversations, perspectives, and ideas, it is natural for some to feel overwhelmed or experience negative feelings such as frustration, irritation, or anger. Members may feel more vulnerable with sharing and may perceive well-intentioned suggestions as “telling them what to do.” In MI groups, group leaders are astute at managing negative emotions, shifting focus away from unproductive conversations, and easing tension so that members feel more comfortable sharing information and receiving suggestions, feedback, and support.

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Moving to Action Moving into action is the final phase of MI groups and analogous to the planning phase of individual MI. Discussion of possibilities cannot go on forever, and so at this point members begin to narrow options and formulate a plan for change. As alluded to earlier, a significant benefit of group counseling is that members can learn vicariously through the actions of other members. Observing group members act and find success in changing difficult behaviors can be both inspiring and motivating. Within this phase, group leaders focus on needs and actions, guiding members toward supporting each other’s self-efficacy, and developing plans for change (Berg, 2015; Wagner & Ingersoll, 2013). Planning for change can include formal activities or informal discussions. For example, MI group leaders can encourage each member to complete a change plan worksheet (Miller & Rollnick, 2002) as they experience increasingly more readiness, willingness, and ability to change. The change plan worksheet formalizes the planning process by helping clients identify and write down several critical factors in making a change, including what needs to change, a timeline, when he or she will know the plan is working/not working, barriers, and supports. Although all group members may not be ready for such an exercise, those who are ready can complete this and share with the group. The group leader and other group members can offer feedback and support. This sharing exercise can be inspirational to other group members who are building and strengthening their own motivation to change but are not yet ready to plan.

Empirical Support Several researchers have examined the efficacy of group-based motivational interviewing, across a wide range of clinical problems. In general, results have supported the use of MI within groups, although the quality of scientific rigor varies greatly from study to study. Perhaps the most frequent application, however, is with the adolescent populations. D’Amico et al. (2015) found group MI a promising intervention for adolescent alcohol and drug use. The researchers found that facilitator open-ended questions and reflections of change talk, two critical components of OARS, increased group change talk, which was followed by increased individual change talk. In addition, group change talk was associated with reduced markers of alcohol use three months later, including decreased alcohol intentions, alcohol use, and heaving drinking. Opposite patterns were noted for group sustain talk; decreased motivation to change, increased intentions to smoke marijuana, and increased drug outcome expectancies. The researchers highlighted the importance of selective reflection of change talk with adolescent substance abuse groups as being a key intervention associated with change.

108 Applications of MI in CMH Settings In another study among first time adolescent alcohol and other drug offenders, D’Amico et al. (2010) found that feedback based on group MI led to higher levels of evocation, collaboration, autonomy/support, and empathy. The authors concluded that utilizing group MI can be a viable strategy for at-risk youth. Beyond substance abuse issues, group MI has been shown to be effective for adolescents struggling with Type 1 diabetes, a problem in need of better coping skills. Knight et al. (2003) allocated 20 adolescents with poorly controlled Type-1 diabetes to either treatment or control conditions. Treatment consisted of “externalizing conversations” combined with group MI. Results indicated that the treatment group felt less threatened with their diagnosis, had more feelings of control, and adopted a perspective of acceptance. Rather than being discouraged, they began to see their diagnosis as having less restrictive impact in their lives. Among older adolescents, LaBrie et al. (2007) sought to study the impact of group MI in reducing drinking and associated negative consequences among adjudicated college women. The participants engaged in one two-hour group intervention focusing on decisional balance and goal setting, among other topics. The researchers found significant reductions in alcohol consumption and negative consequences at the 12-week follow-up. Importantly, the intervention seemed to initiate change among the heaviest drinkers. These results suggest that only one session of group MI can be effective in reducing markers of binge drinking among college women, especially for those at highest risk. The promising effects of group MI with adolescent populations also extends to adults with substance use problems. Lincourt et al. (2002) found that across a two-year period, clients who attended a motivational interviewing group were significantly less likely to meet criteria for a substance use diagnosis, attended more counseling sessions, and were more likely to complete counseling than those who did not attend group treatment. This result held even after controlling for diagnosis, employment, and age. Similar results were found by Rosenblum et al. (2005) and Santa Ana et al. (2007). From this research, we can conclude that group MI may promote more consistent and long-term participation in treatment compared to not receiving any group care. Group MI also has been found to be effective for clients diagnosed with obsessive-compulsive disorder (OCD). Although many clients with OCD show improvement through group cognitive-behavioral therapy (GCBT), a sizable portion fail to follow through with therapy exercises and subsequently do not show therapy gains. In a randomized behavioral trial, Meyer and colleagues (2010) examined the effectiveness of GCBT combined with sessions of MI and thought mapping (TM) compared to GCBT alone. Results showed that the group with the added MI and TM had significantly higher symptom reduction and remission, and improvements were maintained at the three-month follow-up. This research

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suggests that simply adding a session or two of MI before GCBT can improve therapy outcomes for those with OCD. Although not formally assessed in this study, it would not take much of a leap to suggest that using group MI as a prelude to most diagnostic treatment groups have the potential to improve compliance and outcomes. Taken together, these findings suggest that MI groups, or adding an MI component to established groups, tends to enhance effectiveness and improves outcomes. But what principles of MI are key to successful groups? Rose and Chang (2010) suggested several clinical principles for enhancing motivation within groups, including improving treatment goals, enhancing client’s perception of counseling, acceptance of their problems, and working to resolving them. Enhancing motivation includes conceptualizing ambivalence as normal and addressing it before treatment commences. Young (2013) focused on the usefulness of using MI in the early stages of group development by facilitating an atmosphere of trust and recognizing readiness to change. Other principles useful in the early stages of group include resolving ambivalence, identifying personal goals, working with members’ resistance, enhancing motivation to change, and strengthening commitment to change (Young). Using MI as a pre-group treatment also is important for assessing readiness to change (Zalmanowitz et al., 2013). It is likely that these principles combine to enhance overall effectiveness of group counseling. Whether MI is included as a pre-group treatment or infused throughout the group, it seems to enhance its therapeutic impact through both improved outcomes and enhanced participation.

Contraindications We are often asked, “Are there times when MI is not appropriate for group counseling?” We would never say that MI can or should be used in every group situation, with every conceivable issue or problem a group may be facing. Clearly, there are times when group leaders need to be more direct and persuasive, thus moving away from the core guiding stance of MI. Nonetheless, we believe that MI could certainly be implemented in most groups, with the extent depending on the group composition, location, topic, length, and type. Group leaders may, for example, start every group with a focus on MI spirit and skills, and then gradually move on to incorporate other group methods. Others may infuse MI skills and strategies throughout group counseling, keeping MI spirit as an underlying philosophy. And, still others may use MI on an “as needed” basis, where the extent of MI is utilized based on the waxing and waning of motivation that is a part of every individual and group change process. To effectively use MI, clients must have reasonable capacity for selfreflection and motivational assessment. As such, groups who are unable to reflect on issues of self-motivation, change talk, and ambivalence are

110 Applications of MI in CMH Settings probably best suited for a more directive approach. In addition, groups with a focus on trauma, grief, and loss may not respond well to MI, instead needing more support, reassurance, and encouragement than guidance. Let us now turn to a case study example that highlights some of the phases and principles discussed thus far.

Case Study In the following case study, we highlight a clinical example of an outpatient MI group in which the group leader is focusing on exploring perspectives (assume the group has already worked through the earlier phase of engagement). The group is comprised of five members: Stan, a 45-year-old Caucasian male struggling with anxiety; Darren, a 32-year-old African American male struggling with depression and anxiety; Bobbie, a 31-year-old Caucasian female living with depression and sleep issues; Li Jing, a 29-yearold Chinese American female who is struggling with social phobia; and Richard, a 32-year-old male who is struggling with controlling his anger. The group’s primary focus is to help clients increase motivation to make positive changes in their lives. In this case example, the group is focusing on Bobbie and her struggle with depression. Notice how the group leader explores Bobbi’s perspectives of but also connects others to her story. GROUP LEADER:

Right now, let us focus on exploring each other’s situations and lives, and getting to know and understand one another a bit more. The benefit of this is that by hearing from each other, we can widen our own perspectives, goals, and values and how these fit into our lifestyles. By lifestyle, I mean what you do, how you spend your time, and how you live. So, how do you spend your time and what types of daily patterns have you noticed? Anyone can begin. (Introducing the concept of exploring perspectives) BOBBIE: I can go first. As you all know, I am struggling with depression and have trouble staying asleep. It is just hard because I’m exhausted when I come home from work and everyone wants my attention. Since last session, I have noticed a pattern where I tend to watch TV too late and then stay on my device before bed. My diet has gone in the dumps, too. I heard that can help with depression sometimes. GROUP LEADER: Your depression has kind of taken over and at the same time you have noticed some areas that might be causing you to feel down (ending reflection in intentional manner to encourage change talk). BOBBIE: Ya, I just want to feel better. It’s like it is difficult to feel positive any more about my life. GROUP LEADER: Would it be alright if I provide some information? [group nods; asking permission]. Sometimes happiness is a function of living in accordance with our values. That is, asking ourselves if we are

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living according to what we see as important and consistent with a healthy life. If our behaviors are inconsistent with what we see as important, then we usually are not finding the satisfaction in life we want and deserve. Bobbie, let’s explore what you value and see as important in your life. BOBBIE: My kids are so important to me; I think about their safety and happiness all the time. I also value my health although I don’t think I am doing a very good job helping myself! GROUP LEADER: [to the group] Keeping consistent with our desire to explore perspectives, how can we help Bobbie take a wider view of her experience of depression? LI JING: Bobbie, I am wondering about what you say you value and your actions. For example, how does staying up late watching TV and eating poorly connect with your value of wanting to be healthy? [building discrepancies between goals and values]. BOBBIE: That is just it . . . there is no connection. These are just bad habits that I fell in to, and now I am beginning to see how they may be exacerbating my depressed feelings. There are probably other bad habits that I have not shared. RICHARD: We seem to always be tempted to live outside our values. We say something or someone is important, but our actions tell a different story. This is definitely the case in my life, where my value of being centered and calm conflicts with the frequent chaos in my life. Bobbie, I wonder what that would look like for you, if you were to better align your behaviors and values [continuing to explore perspectives, without giving direct advice]. BOBBIE: Thanks, Richard. It is helpful to hear other struggles with discrepancies between values and goals. If my goals and values were more consistent, I would be a better parent and a better person to myself. I feel I would grow in confidence and energy. Although my depression probably stems from additional issues, that would be start. DARREN: I hear what you are saying, Bobbie. Just know that you are not alone as I have experienced some depression as well. This discrepancy talk has helped me focus on what is important (expressing empathy). STAN: I never considered how living according to our values enhances mental health. It makes sense, though. I wonder if we all picked one value to live by for the next week, what would happen? GROUP LEADER: That sounds like a great idea, Stan. And let’s hold off on behavior change until we get a clear picture of everyone’s lifestyle and life perspective [affirming and being careful not to move the group to fast into planning]. Bobbie, what do you make of all that you have heard so far about your daily patterns and lifestyle? BOBBIE: Well, it really helps knowing that everyone here struggles with being consistent in their behaviors and values. Clearly there are

112 Applications of MI in CMH Settings things that I can do to be healthier and get better sleep. I feel motivated now to try these out as a starting point to feel better. GROUP LEADER: Hearing that others have similar struggles is helpful and you feel some energy to change behaviors in your routine (complex reflection). In this short vignette, we see the group leader intentionally helping one member, Bobbie, explore perspectives and her lifestyle habits with an eye on developing discrepancies. Notice that Stan offered a challenge to the group—for everyone to change one behavior to live more consistently with one’s values. The group leader validated Stan’s suggestion; however, he also was careful not to move too quickly into planning before exploring and broadening perspectives. Analogous to individual MI, moving too quickly to planning, before motivation and readiness to change have been fully vetted, can result in backsliding and resurgence in resistance and/or discord.

Summary Group counseling is a well-regarded modality of counseling that has some unique advantages over individual counseling. Although MI was originally formulated as a brief individual approach, there has been increasing interest and application with group counseling. Many of the “curative factors” that make group counseling effective align with the philosophy of MI. The foundation of individual MI principles can extend to MI group therapy, although the application requires some adjustment given the greater number of clients within a group setting. Activities and Resources 1. Berg (2015) has a very handy note sheet based on Wagner & Ingersoll’s book, Motivational Interviewing in Groups (see references for full citation). It can be accessed at https://tinyurl.com/5352p5ft. 2. One of the early conundrums of providing MI within groups is that group members do not have the same levels of motivation, necessitating differing interventions. However, there are several MI techniques that can be applied no matter the group members’ readiness to change and motivation. What might some of those techniques be? How can MI be effective with groups in which members have differing levels of motivation? Discuss this possibility with a colleague or fellow student.

References Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215.

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Berg, J. (2015). Notes from motivational interviewing in groups (2013 Wagner & Ingersoll). Unpublished document. Retrieved from https://tinyurl.com/5352p5ft Brooks, F., & McHenry, B. (2015). A contemporary approach to substance use disorders and addiction counseling (2nd ed.). American Counseling Association. D’Amico, E. J., Houck, J. M., Hunter, S. B., Miles, J. N., Osilla, K. C., & Ewing, B. A. (2015). Group motivational interviewing for adolescents: Change talk and alcohol and marijuana outcomes. Journal of Consulting and Clinical Psychology, 83(1), 68. D’Amico, E. J., Osilla, K. C., & Hunter, S. B. (2010). Developing a group motivational interviewing intervention for first-time adolescent offenders at-risk for an alcohol or drug use disorder. Alcoholism Treatment Quarterly, 28(4), 417–436. Fawcett, E. R., Neary, M., Ginsburg, R., & Cornish, P. (2020). Comparing the effectiveness of individual and group therapy for students with symptoms of anxiety and depression: A randomized pilot study. Journal of American College Health, 68, 430–437. http://doi.org/10.1080/07448481.2019.1577862 Foote, J., DeLuca, A., Magura, S., Warner, A., Grand, A., Rosenblum, A., & Stahl, S. (1999). A group motivational treatment for chemical dependency. Journal of Substance Abuse Treatment, 17(3), 181–192. Katz, L. S. (2016). Efficacy of Warrior Renew group therapy for female veterans who have experienced military sexual assault. Psychological Services, 13, 364–372. Knight, K. M., Bundy, C., Morris, R., Higgs, J. F., Jameson, R. A., Unsworth, P., & Jayson, D. (2003). The effects of group motivational interviewing and externalizing conversations for adolescents with Type-1 diabetes. Psychology, Health & Medicine, 8(2), 149–157. Krejci, J., & Neugebauer, Q. (2015). Motivational interviewing in groups: Group process considerations. Journal of Groups in Addiction & Recovery, 10, 23–40. LaBrie, J. W., Thompson, A. D., Huchting, K., Lac, A., & Buckley, K. (2007). A group motivational interviewing intervention reduces drinking and alcoholrelated negative consequences in adjudicated college women. Addictive Behaviors, 32(11), 2549–2562. Lincourt, P., Kuettel, T. J., & Bombardier, C. H. (2002). Motivational interviewing in a group setting with mandated clients: A pilot study. Addictive Behaviors, 27(3), 381–391. Meyer, E., Souza, F., Heldt, E., Knapp, P., Cordioli, A., Shavitt, R. G., & Leukefeld, C. (2010). A randomized clinical trial to examine enhancing cognitivebehavioral group therapy for obsessive-compulsive disorder with motivational interviewing and thought mapping. Behavioural and Cognitive Psychotherapy, 38(3), 319–336. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Helping people change addictive behavior. Guilford. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). Guilford. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford. Owen, M., Sellwood, W., Kan, S., Murray, J., & Sarsam, M. (2015). Group CBT for psychosis: A longitudinal, controlled trial with inpatients. Behaviour Research and Therapy, 65, 76–85.

114 Applications of MI in CMH Settings Rose, S. D., & Chang, H. S. (2010). Motivating clients in treatment groups. Social Work with Groups, 33(2–3), 260–277. Rosenblum, A., Magura, S., Kayman, D. J., & Fong, C. (2005). Motivationally enhanced group counseling for substance users in a soup kitchen: A randomized clinical trial. Drug and Alcohol Dependence, 80(1), 91–103. Santa Ana, E. J., Wulfert, E., & Nietert, P. J. (2007). Efficacy of group motivational interviewing (GMI) for psychiatric inpatients with chemical dependence. Journal of Consulting and Clinical Psychology, 75(5), 816. Sobell, L. C., & Sobell, M. B. (2011). Group therapy for substance use disorders: A motivational cognitive-behavioral approach. Guilford Press. Tuckman, B. W., & Jensen, M. A. (1977). Stages of small group development revisited. Group Organizational Studies, 2, 419–427. Velasquez, M. M., Stephens, N. S., & Ingersoll, K. (2006). Motivational interviewing in groups. Journal of Groups in Addiction and Recovery, 1, 27–50. Wagner, C. C., & Ingersoll, K. S. (2013). Motivational interviewing in groups. Guilford. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). Basic Books. Young, T. L. (2013). Using motivational interviewing within the early stages of group development. The Journal of Specialists in Group Work, 38(2), 169–181. Zalmanowitz, S. J., Babins-Wagner, R., Rodger, S., Corbett, B. A., & Leschied, A. (2013). The association of readiness to change and motivational interviewing with treatment outcomes in males involved in domestic violence group therapy. Journal of Interpersonal Violence, 28(5), 956–974.

7

Client Conceptualization Using Motivational Interviewing Within the Clinical Evaluation Process

Introduction Clinical evaluation comprises a significant part of the everyday activities of clinical mental health (CMH) counselors. Whether counselors are utilizing well-established personality assessments, brief assessment procedures, or their own clinical hunches, evaluation is a constant, and constantly changing, process within client care. Clinical evaluation is a primary avenue to help counselor better conceptualize client problems and can provide insight that may not be forthcoming through client– counselor dialogue. In this chapter, we will cover a broad overview of the clinical evaluation process from screening to diagnosis. Although this information is important to provide a context for the chapter, our purpose is not to provide an exhaustive review of clinical evaluation and assessment methods (for a more in-depth treatment of clinical assessment, see Hayes (2017). We then detail how motivational interviewing (MI) fits within the clinical evaluation process and where it can be particularly useful, especially related to providing clinical feedback. Finally, we examine some specific assessment tools closely aligned with MI to help clinicians evaluate a client’s readiness to change and degree of motivation.

Clinical Evaluation Clinical evaluation plays a key role in helping our clients make positive changes in their lives. Although it is tempting to believe that clinical evaluation occurs only at the beginning of counseling, in a sense we are always evaluating our clients, even if not using a formal assessment instrument. Clients present with a myriad of information, including signs and symptoms of mental health issues, family history, motivation levels, and relationship struggles that can expand or change over time. We believe a proper and thorough evaluation helps the mental health counselor to determine (a) the degree and extent of clinical symptoms and associated features, (b) how much these symptoms are interfering with the client’s life, DOI: 10.4324/9781351244596-9

116 Applications of MI in CMH Settings

Evaluation

Diagnosis

Screening Assessment

Figure 7.1 The Clinical Evaluation and Its Components

(c) the extent of consequences related to symptoms, (d) insight into what historical, social, cultural, familial, or contextual factors play a role in the development and maintenance of these symptoms, and (e) a diagnosis and treatment plan. Clearly, the clinical evaluation, whether done formally or informally, sets the stage for conceptualization and setting a treatment strategy. In general, three components make up the clinical evaluation: screening, assessment, and diagnosis (see Figure 7.1). Screening Screening is the first step in the clinical evaluation process. Its function is to help clinicians rule out certain issues that otherwise may need clinical attention. Clinicians can target their screening efforts toward specific mental health issues, such as depression, or “cast a wide net” to see if clients identify mental health concerns among a range of presenting symptoms. Clinical screening is relatively brief—perhaps up to 10 minutes or so—and designed to give the clinician a quick snapshot into potential clinical problems or diagnoses. If the screening process uncovers likely clinical difficulties, then more formal, in-depth assessments are warranted. For example, the Beck’s Depression Inventory (BDI; Beck et al., 1996) is a well-established screening tool for clinical depression. It takes about 10 minutes to complete, and scores range from minimal (or no) depression (a score between 0 and 13), mild depression (a score between 14 and 19), moderate depression (a score between 20 and 28) and severe depression (a score between 29 and 63). Clients who score in the moderate to severe range would be good candidates for further assessment into the nature of the depressive symptoms, underlying causes, and severity. Another common screening tool is the CAGE assessment (Ewing, 1984), designed to screen for potential alcohol problems. The client is asked four questions: Has anyone ever recommended that you cut back

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or stop drinking? Have you ever felt annoyed or angry if someone comments on your drinking? Have there been times when you have felt guilty about or regretted things that have occurred because of drinking? Have you ever used alcohol to help you get started in the morning to steady your nerves? Two or more positive responses may indicate an alcohol problem, in which case further assessment is warranted. Assessment The next process in clinical evaluation is assessment. Although clinical assessment is like screening in that the clinician gathers important information regarding presenting signs and symptoms, assessment is generally more in-depth and is usually targeted toward a specific problem (however, some clinical assessments are designed to be broad surveys of client symptoms). For example, if a client answered “yes” to three out of four CAGE questions, indicating the likelihood of a severe alcohol problem, the clinician could administer the Alcohol Use Inventory (AUI; Horn et al., 1990) for a more in-depth look at drinking. The AUI takes about 35–60 minutes to complete and provides a range of information on the intensity, consequences, and styles of client drinking, in addition to comparing these patterns to a normative sample of those in inpatient alcohol treatment. Of course, the AUI would not be warranted without the initial CAGE screening; it would be inappropriate, and perhaps a waste of time and resources, for the clinician to jump right to administering the AUI without knowing if alcohol issues were a possibility in the first place. Assessments can range from 30 minutes to several hours, depending on agency policy, clinical goals, and specific information requested. The Clinical Interview The clinical interview is typically performed in the first counseling session but could extend into several sessions depending on how much detail is requested and offered. The clinical interview also is referred to as the intake interview, intake assessment, or diagnostic assessment, although slight variations in all these procedures may exist. The clinical interview is usually a structured process performed with a preset list of questions about what brings the client to counseling; ideally, the client provides enough detail for the clinician to record and to aid in the clinical evaluation. However, many clinicians opt for a semi-structured clinical interview, in which they follow a prescribed set of questions, but have flexibility to deviate from these questions as warranted. For example, if during a clinical interview the client shared a recent loss in his or her family, the clinician might put aside the questioning and explore thoughts and feelings the client is experiencing in the moment. After this initial exploration, the clinician gently returns to the interview questions.

118 Applications of MI in CMH Settings The communication style of MI is well-suited for clinical interviewing. As will be outlined later, infusing MI into the clinical interview process helps build rapport and is a natural time to exude MI spirit. The clinical interview combined with MI can feel less like an interrogation and more like a conversation. THE MENTAL STATUS

As part of the clinical interview, mental status is most often performed through observation. The clinician observes the client’s orientation, appearance, speech, thought processes, mood, etc., and identifies anything that is peculiar or noteworthy. For example, a clinician might note that a client was oriented to time, person, place, and situation, that her appearance and dress were unremarkable (i.e., nothing peculiar noted), but that her mood seemed down as evidenced by her slow, methodical speech. Admittedly, the mental status performed in this manner is a subjective process and based purely on clinician observation. In some CMH settings, such as residential or inpatient facilities with a medical component to treatment (having a psychiatrist or medical doctor on the treatment staff), the mental status exam is more objective and thorough. For example, a client might go through specific tests of recall, memory, and orientation by counting backward from 100 by 7s, recalling a list of words presented earlier in the session, and verbalizing the current day, time, and location. A clinician then scores the exam providing greater insight into the client’s mental health and functioning. Which method clinicians use for the mental status depends on several factors, including setting, clinical experience, training, and agency preference. However, most outpatient mental health clinics will use the former method as this can be easily incorporated into the clinical interview. The mental status exam does not need to be a formal procedure, although it does require good observational skills on the part of the clinician. Regardless, the mental status, whether using observation, formal testing, or some combination, can be an important addition to the information gathering process. Assessment Instruments CMH professionals can enhance their assessment procedures by using formal psychological instruments to gather in-depth information about client symptoms and struggles. Two examples include the Minnesota Multiphasic Personality Inventory—3 (MMPI-3; Ben-Porath & Tellegen, 2020), and the Millon Clinical Multiaxial Inventory—IV (MCMI-IV; Millon et al., 2015). Both instruments are lengthy personality assessments that provide detailed information about the clients’ test taking attitudes, personality patterns, interpersonal patterns, symptom profiles, diagnostic

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considerations, and treatment recommendations. Information from these instruments can be helpful when clinicians need additional assistance in conceptualizing the client’s personality and functioning. Most instruments can be completed via paper-pencil or through a computer system; through a computer system, the client’s responses are scored, interpreted, and reported with the push of a few keys. However, computerized assessment reports are just that—computerized reports. I (TFL) find these reports useful, but computers do not know my clients’ backgrounds the way I do. The reports often are written from a deficit-based perspective, pointing out what is wrong with the client but neglecting strengths or affirming positive character. They definitely do not follow an MI approach! As such, we recommend not giving clients computerized assessment reports. Instead, we encourage clinicians to use these reports as a guide and write their own report that includes contextual factors, client insights, and strengths. Although this involves a bit more time, it is well worth the effort as we strive to provide balanced feedback on what the client is doing well, and areas that need improvement. The MMPI-3 and the MCMI-IV are just two examples of assessment instruments used in the CMH setting. There are probably hundreds of well-regarded assessment instruments from which the clinician can choose depending on his or her area of specialty, specific client issues, interest, or agency protocol. Assessment instruments can assess broadly or focus on a single problem. It is ultimately up to clinicians to decide which instruments they want to incorporate into their practice. From an MI perspective, it doesn’t matter which assessment process or instrument is used; what does matter is the way assessment feedback is provided to the client, a topic we will turn to later in the chapter. Diagnosis Diagnosis is the next step in the evaluation process. After screening and assessment, the clinician determines if the client’s signs and symptoms match established criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5; APA, 2013). Diagnosis presents somewhat of a conundrum for CMH counselors because the philosophy behind diagnosis is perceived by some to be at odds with the philosophy behind counseling (and MI for that matter). That is, diagnosis is predicated on the disease or medical model, in which the objective is to find out what is wrong with the client (or where he or she has a deficit). On the other hand, professional counseling originated from educational, developmental, and wellness-based perspectives, where clinicians focus on strengths and what is working in the client’s life. This is not to say that CMH counselors never look for problems or ignore diagnoses; however, the challenge is to find a way to use diagnosis where

120 Applications of MI in CMH Settings clients feel empowered, while at the same time building on what is already working in their lives.

Motivational Interviewing and the Evaluation Process MI can serve as an important tool in the evaluation process. It is interesting to note that within the name “motivational interviewing” is the word interview. Webster’s Online Dictionary (Interview, 2021) provided two overlapping, if insightful, definitions of interview: (a) “A mutual sight or view; a meeting face to face, usually a formal or official meeting for consultation; (b) A conversation, or questioning, for the purpose of eliciting information for publication” [italics added for emphasis]. The creators of MI choose the word “interviewing” because its definition reflects the style of the approach: mutuality, a meeting between two people, consultative, conversational, and a drawing out of information (i.e., evoking). The contribution MI makes to clinical evaluation is to infuse the process with a spirit and set of skills designed to build rapport and lower discord. Doing so increases the chances of clients sharing what is bothering them and having a positive, informative experience through the evaluation process. Using Motivational Interviewing During the Clinical Interview The clinical interview is often the first contact mental health counselors have with their clients. In our experience, the first session is critical for developing rapport and can go a long way in determining if the client will return to counseling. The first process of MI, engagement, is an excellent method for building rapport. We often encourage our students to start off every counseling session with MI to get their foot in the door. The strategic use of blending questions, reflections, and affirmations, in the context of MI spirit, place clients at greater ease throughout the process. The reductions in discord and resistance pave the way for openness, receptivity, and building the clinical relationship. MI spirit and skills (OARS) can be used throughout the evaluation process, and we encourage counselors to infuse MI into this clinical obligation whenever possible. For example, when conducting a clinical interview, the clinician can intersperse reflective statements between client responses to interview questions. Consider offering a menu of assessment options from which the client can have a say. This illustrates collaboration and partnership, the first aspect of MI spirit.

Assessment Feedback and Motivational Interviewing Perhaps the greatest contribution MI makes to clinical evaluation is in the assessment feedback process. Feedback is a powerful and motivating

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force for behavior change (Miller & Rollnick, 1991). In fact, even without formal intervention, strategic feedback can set in motion motivational processes that can gently push the client in the direction of change. This is likened to a patient who visits a physician and receives feedback that her cholesterol is high, and that a healthier diet and exercise may help reverse this trend. Just hearing feedback can be enough to motivate a person to change (Miller & Rollnick, 1991). Below, we offer two models of providing feedback grounded in MI methods—E-P-E and FRAMES Elicit-Provide-Elicit (E-P-E) Information from screening instruments, interviews, or clinical assessments can be overwhelming for clients, especially if the feedback is negative. The elicit-provide-elicit (E-P-E) strategy was created by (Rollnick et al., 2008) to provide critical feedback to clients, but in a manner that encourages reflection, processing, and evoking client thoughts and feelings. The E-P-E process begins with asking the client if he has any thoughts about the evaluation process or specific assessments and what if anything would he like feedback on first (elicit). After the client shares his thoughts, the counselor then offers a small amount of information about the evaluation (provide). From there, the counselor then asks the client what he makes of the information, or about any reactions (elicit). The client then shares his thoughts, feelings, and/or reactions, which is followed by the counselor providing more information (provide). This process of elicit— provide—elicit continues until the evaluation feedback is complete. It is important when using E-P-E that the counselor keep chunks of feedback (i.e., provide) small so that the client can process what is said. Otherwise, the client may miss information or tune out, leading to increased discord. The beauty of the E-P-E strategy is that it can be a feedback model for any evaluation or assessment activity, across multiple mental health counseling settings, in which there is a distinct feedback component between counselor and client. A brief clinical vignette illustrates. COUNSELOR:

Hello Jake. Thanks for coming in today. As you know, you completed the MMPI-3 last week, and I have the assessment scored and feedback based on the results. First, though, I’d like to get a sense of what taking a test like this was like for you? (Elicit) CLIENT: Well, it was very long. I know you warned me about that but I got a little tired toward the end. Some of the questions were kind of weird, too. COUNSELOR: Yes, a test this long can be tiring and the forced choice format can sometimes be frustrating. Is there anything in particular that you are wondering about the assessment? (Reflection followed by continuation of the elicit portion)

122 Applications of MI in CMH Settings Not really. But I am curious what the test showed about what I am experiencing. COUNSELOR: Great, let’s start by looking at the results about how you approached the assessment and responded to the items. Based on your responses, you answered all the items and didn’t try to portray yourself in an overly positive or negative light. This is important because it means we can have confidence in the rest of the assessment results (provide). COUNSELOR: What do you make of that? (elicit) CLIENT:

In this vignette, the reader can see how the E—P—E process unfolds. Continuing with this process, the counselor provides more and more information and feedback to the client, interspersed with eliciting client thoughts, feelings, and reactions. FRAMES Another useful model for providing evaluation feedback is based on the acronym FRAMES (Bien et al., 1993), which stands for feedback, responsibility, advice, menu, empathy, and self-efficacy. FRAMES is a brief motivational intervention model based on a review of the literature conducted in the early 1990s, where researchers wanted to isolate the “active ingredients” of brief motivational interventions (Bien et al.). Their conclusion came to the acronym FRAMES. Because clinical evaluations by themselves are relatively brief in nature (i.e., taking between one and three clinical sessions), the FRAMES model can be an excellent way to “frame” (no pun intended) the evaluation feedback process. As noted, the first letter stands for feedback, which usually comes from screening or assessment instruments. In addition to feedback, the counselor emphasizes personal responsibility, consistent with MI’s focus on client autonomy. Information and advice are provided in an MI-consistent manner (i.e., asking permission first, then offering information). Clients are provided a menu of “next steps” or treatment options, usually consisting of two to three choices if possible. Empathy is present throughout this process, as well as a focus on self-efficacy. These five “active ingredients” are not meant to be offered in a linear fashion, but rather incorporated within sessions to bolster motivation, especially if the counselor has only a brief amount of time. Let’s look at a similar brief clinical vignette as above, but this time using some aspects of the FRAMES model. COUNSELOR:

Hello Jake. Thanks for coming in today. As you know, you completed the MMPI-3 last week, and I have the assessment scored and feedback based on the results. I would like to discuss the results if that is ok with you.

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Ya, that is fine. I’ve been looking forward to seeing what I can learn about myself. COUNSELOR: Before we begin, though, I’d like to stress that what you do with this feedback is entirely up to you; I would imagine that some results will fit and some not so much, but it is up to you how you apply the information. (emphasizing responsibility) CLIENT: [Nods in agreement]. COUNSELOR: Ok, let’s start by looking at the results about how you approached the assessment and responded to the items. Based on your responses, you answered all the items and didn’t try to portray yourself in an overly positive or negative light. This is important because it means we can have confidence in the rest of the assessment (giving feedback). CLIENT: That is good. I tried to answer as honestly as possible. COUNSELOR: (provides additional feedback from the MMPI-3, using the E—P—E method) . . . CLIENT: So, what does all this say about my treatment or counseling? What is the next step? COUNSELOR: Well, the assessment seems to have helped us home in on what, specifically, is creating problems in your life and what might be behind them. There are a few options to consider. First, you could continue individual counseling, where you and a counselor can focus on your goals and best match a treatment approach to these goals. A second option would be to join a CBT counseling group once a week for 10 weeks. CBT stands for cognitive behavioral therapy, an approach that helps clients examine how their thinking gets in their own way. And, a third option would be to engage in a combination of individual and group counseling for the next several weeks. (Providing a menu of options). CLIENT: I am not sure what to do. COUNSELOR: Would it be alright if I offer some more information about these options? [Client nods and counselor provides more details about individual, group, and combined counseling options] (offers advice/information). CLIENT: I think I’m interested in the individual counseling at the moment. I may be more interested in group counseling down the road. COUNSELOR: That is always an option. There is definitely not one right way to approach treatment. And, since coming to the clinic, you have already made good strides in feeling better (supporting self-efficacy). CLIENT

From this vignette, we see several of the FRAMES components: feedback, responsibility, advice, menu, and self-efficacy. Keep in mind that counselors do not need to follow these interventions in a linear fashion or even incorporate all of them within a session. In addition, the menu of options above is just one example of what this might look like; depending

124 Applications of MI in CMH Settings on one’s setting and circumstances, a menu could look very different. If a menu of options is not possible (e.g., a client severely addicted to alcohol and who has concomitant physical and psychological consequences probably doesn’t have much wiggle room other than to abstain from alcohol), counselors should be honest and stress the client still has autonomy in deciding to continue treatment or not. Also note how the counselor infused some E-P-E while using the FRAMES model. The two approaches are certainly not mutually exclusive and can be strategically blended within the feedback process.

Assessing Stages of Change and Motivation Stages of Change The stages of change or transtheoretical model (TTM; Prochaska & DiClemente, 2005) suggests that in any change process, individuals will pass through a series of stages, each defined by greater levels of motivation and movement toward change. If you recall from Chapter 1, the six stages include precontemplation, contemplation, determination, action, maintenance, and relapse. The stage of change in which a client is in can be deciphered by their corresponding attitudes and thoughts about change. For example, precontemplators will not be interested in change and see no reason for it, despite mounting negative consequences in their lives. Those in contemplation will typically be ambivalent about change, stating reasons for and against the status quo. As clients move through the stages, counselors will see greater motivation and commitment in words and actions. Although not emphasized as much in more recent MI writings, the TTM still serves as a useful framework from which to choose motivational interventions. For example, for precontemplative clients, strategies such as consciousness raising, exploring the pros and cons of behavior, and querying extremes (exploring the worst case/best case scenarios if the client didn’t change) could be useful methods to help clients give more thought to behavior change. However, for clients who are in the action stage, strategies such as building confidence and planning become more useful. A counselor who is not cognizant of the client’s stage of change nor flexible in techniques of motivation enchantment run the risk of engendering more resistance and discord (this point was briefly touched on in Chapter 1). Motivation The TTM model clarifies how resistance and discord can emerge in the clinical setting. It reminds clinicians not to assume clients are ready for action from the start; client engagement is maximized when interventions

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match the client’s stage. The TTM model and MI “grew up” together in the 1980s and unfortunately became synonymous in clinical circles (Miller & Rollnick, 2009). However, despite some parallels, they are not the same, and MI has distanced itself from TTM in more recent writings (e.g., Miller & Rollnick, 2013). From an MI perspective, assessing motivation necessitates examining its anatomy; namely, importance, confidence, and readiness. Before we dive into these three areas of motivation assessment, a word about finding a target for change. As noted in Chapter 4, the focusing process encourages clinicians to get clarity and focus within a session, otherwise MI is difficult to apply. Ideally, targets for change are specific behaviors, such as stopping substance use or healthier eating. However, a target may be vaguer, such as reducing feelings of depression or wanting to engage in self-growth (Miller & Rollnick, 2013). In these instances, exploring what behaviors are associated with such goals can help specify the target (i.e., one target may have many behaviors for change associated with it). Importance The first step in assessing client motivation is to determine how important change is to the client. If clients believe the importance of changing is high, they will have greater energy and momentum for change. However, when there is little or no importance given to change, counseling becomes more challenging. Clients low on importance is analogous to those who are precontemplative in the TTM; there is no urgent need for change despite numerous consequences. The client may think he does not have a problem and that everyone is just making a big deal out of his behavior. One way to assess importance is to use a scaling question, such as, “On a scale of 1 to 10, with 1 being not important and 10 being very important, how important is making [specific change] to you?” The answer provides an estimation of the client’s perceived importance of the problem. Another method would be to simply have an open conversation about the importance of change. With skillful use of OARS, clinicians can gauge importance through dialogue with questions such as, “How important is change to you?” or “Why would you need to make this change?” Confidence Confidence is about the “how to” of motivation. It gets at ability; sometimes clients feel that it is very important to change, but do not feel that they know how to change. As with importance, clinicians can assess confidence using a scaling question (e.g., “On a scale of 1 to 10, with 1 being no confidence and 10 being very confident, how confident are you that you could make [specific change]).

126 Applications of MI in CMH Settings IMPORTANCE AND CONFIDENCE

The importance/confidence assessment is particularly useful in the first sessions of MI.Where clients lie on these scales determine where the energy should go within the clinical hour. There are four possible scenarios: Clients are (a) low importance/high confidence, (b) low importance/low confidence, (c) high importance/low confidence, or (d) high importance/ high confidence. Each of these domains is observed in Table 7.1. Clients who are low on importance and high on confidence do not see change as important; however, if they had to change, they feel assured that they could. In these instances, clinical focus should be placed on helping clients increase the importance (strategies for increasing importance were outlined in Chapter 3). Clients in this quadrant present significant motivational challenges for the clinician. Clients do not want to be in counseling, do not make change a priority, and otherwise show significant resistance and/or discord. Using MI spirit, OARS, developing discrepancies, and other strategies, MI clinicians gently explore the client’s behavior, lower discord, and help the client find their own intrinsic motivation to change. Clients who are low on importance and low on confidence also present clinical challenges. Here, change is simply not a priority and, if it was, the client does not believe she has to be ability to do so anyway. Clients in this quadrant are likely to be coerced to attend counseling from an outside source such as the legal system or a loved one. As with those low on importance, using MI spirit, OARS, developing discrepancies, and other strategies can help propel these clients to increase both importance and motivation for change. Clients who are high on importance and low on confidence struggle with their ability to change. They don’t dispute the need for change and may even offer significant change talk. The clinical focus, then, is to help explore and practice how to change (several strategies were outlined in Chapter 3). It is a mistake, however, to assume that increasing confidence is somehow easier because importance is already high. The reasoning goes something like this: If the client already knows it is important to change, then the difficult part is over. All the clinician needs to do is focus on how the client will change by offering several ideas.

Table 7.1 Assessing Importance and Confidence to Understand Motivation Importance 

Confidence

 

Low

High

High

Low importance High confidence Low importance Low confidence

High importance High confidence High importance Low confidence

Low

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Keep in mind that motivation is a fluid concept, with natural ebbs and flows in its intensity and expression. Clients may see the importance of change but experience moments where they question its relevance. When importance is high, the temptation for clinicians is to fall back into the righting reflex, offer unsolicited advice, and assume the client needs to just practice a few suggestions. Miller and Rollnick (2013) stressed the significance of keeping consistent with MI spirit and skills, even when moving toward building confidence and increasing action. Building confidence involves continued exploration with the client about strategies that facilitate change, while at the same time being cognizant of shifts or backsliding in the importance of change. Readiness A third component of motivation assessment is readiness to change. As with importance and confidence, readiness can be explored using a similar scaling question as described previously. Readiness is best assessed after exploring and building both importance and confidence. High readiness to change suggests that clients are highly motivated, seeing both the importance of change and feeling confident that they can do so. Change talk is usually consistent with more mobilizing and committed language (e.g., I intend to follow this wellness plan). Readiness gets at the “when” question (i.e., when would be the right time to change?). Thus, if a client indicates he is ready, the time for change is usually now. Although readiness to change is an important consideration, MI places greater emphasis on assessing (and, if needed, increasing) importance and confidence. Usually, by the time clients are high in importance and confidence, they are already making changes, and assessing readiness becomes unnecessary. Nonetheless, clinicians are free to assess for readiness should they believe this would be relevant for the clinical situation, or to check in on the timeframe for change. Change Talk Change talk was discussed at length in Chapter 3. We mention it briefly here to point out the MI clinician’s responsibility to listen for and respond to change talk whenever clients offer it. In evaluating motivation, the amount and quality of change talk are important considerations when assessing the overall picture of the client’s motivation level. Assessment Instruments and Activities Assessment instruments in MI generally fall into two camps: First are assessments that target clinician behaviors in session to determine fidelity to the approach. For example, the Motivational Interviewing Treatment

128 Applications of MI in CMH Settings Integrity Scale (Moyers et al., 2014) now in its fourth iteration, helps clinicians, supervisors, and coaches code MI-adherent and MI-nonadherent behaviors. Such scales are quite useful in providing feedback to improve MI skills. Second are assessment instruments designed to explore client readiness to change and client feedback on the counselor’s use of MI. Because these assessment instruments play a key role in the training and professional development of clinicians practicing MI, they will be reviewed in greater detail in Chapter 10. Other MI related activities fall under the umbrella of assessment, although without a formal instrument. For example, the values clarification card sort (Miller et al., 2001) exercise is utilized to assess a client’s top values. It can be an excellent conversation starter about what is important in the client’s life and how his or her current actions are consistent or inconsistent with chosen values. The idea, of course, is to help clients see a mismatch, if any, between values and behaviors (i.e., develop discrepancy). Clients often are taken aback by how their behaviors run counter to what they say is important. This insight can be motivational because the usual response is increased energy to change behavior to better match values. I (TFL) also have explored what clients find least valuable in their life. On occasion, the client and I discover that some of their problem behaviors are consistent with what they do not value. Again, this bit of assessment, clarification, and insight can be taken a long way in helping clients re-evaluate their life. The personal values card sort and instructions are in the public domain and can be found at the links at the end of this chapter. Other MI assessment activities include the change plan worksheet and methods to elicit change talk. These methods were discussed at length in Chapters 4 and 3, respectively, and will not be reviewed again here. However, from an evaluation perspective, the change plan worksheet is an MI assessment activity for clients who are approaching the planning process of MI (Miller & Rollnick, 2002). It is a clinical aid to assess a client’s plan for change and strengthen commitment to change. The methods to elicit change talk, specifically the DARN CATS acronym, help clinicians assess the level and depth of change language, which can be a harbinger for actual behavior change. Although these methods do not involve a formal assessment instrument, they serve as important activities in the assessment of motivation, desire for change, and commitment. Links to the change plan worksheet can be found at the end of the chapter.

Summary One of the key clinical evaluation teaching points we make to our graduate students is that it is not only what you report back to the client related to assessment, but how the information is provided. An underlying

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premise of MI is that counselor behavior can go a long way in how a client responds in session. This premise is no different during the evaluation process: Engage in too much confrontation or overwhelming the client by taking an overly expert stance, expect more discord and less engagement from clients. Provide information using MI spirit and skills as the backdrop, expect more engagement and quicker movement through the processes of MI. In Chapters 1–4, we outlined the basic tenets of MI spirit and skills and will not re-state in detail here. It is worth repeating, however, that we advocate incorporating MI spirit and skills within any clinical evaluation process, even if the counselor adopts other approaches or theories. The spirit and skills of MI are well suited to build rapport and get you started on the right note. Typically, evaluation procedures are performed on the front end of the counseling process, where first impressions can make the difference between if a client continues in the counseling process or not. Activities and Resources 1. If you teach a course in clinical assessment, it may be worthwhile to spend time helping students to find a style in providing feedback to clients regarding assessment results. Whereas feedback can be directive, where the counselor does the share of the talking, encourage students to practice OARS within the context of feedback. Having students role play in class or observe video demonstrations can be helpful ways to practice using MI in these contexts. 2. Partner up with another person and pick an area of expertise in which you feel you can educate your partner. Start talking about this topic, but make sure to stop after providing a few comments. Check in with the other person to see what his or her thoughts are about what you just said. After your partner speaks, reflect. Reverse roles to practice. 3. The evaluation process naturally leads to treatment planning in CMHC. How might counselors use MI when engaging in treatment planning. What skills would be relevant in these contexts? Resources 1. www.motivationalinterviewing.org/motivation-interviewing-resources. This is from the main MINT and MI website. The website has an entire library on the application and training in MI. Several links are helpful to clinicians and activities to assess motivation within clients. 2. Miller, W. R., Rollnick, S., & Moyers, T. B. (1998). Motivational interviewing: Professional training videotape series. United States:

130 Applications of MI in CMH Settings The University of New Mexico. Besides providing an excellent overview and demonstration of MI, one video provides an excellent demonstration of using MI and E-P-E as a strategy to provide substance use assessment to a client. The video can be purchased at https:// secure.touchnet.com/C21597_ustores/web/product_detail.jsp 3. Personal values clarification card sort—https://motivationalinterviewing.org/personal-values-card-sort. Personal values clarification instructions—https://motivationalinterviewing.org/personal-values-card-sort-instructions. 4. Change plan worksheet—https://motivationalinterviewing.org/changeplan-worksheet.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). APA. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the beck depression inventory-II. Psychological Corporation. Ben-Porath, Y. S., & Tellegen, A. (2020). Minnesota multiphasic personality inventory—3. Pearson Assessments. Bien, T., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, 315–336. Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252, 1905–1907. Hayes, D. G. (2017). Assessment in counseling: Procedures and practices (6th ed.). American Counseling Association. Horn, J. L., Wanberg, K. W., & Foster, F. M. (1990). Guide to the alcohol use inventory (AUI). National Computer Systems. Interview. (2021). In Webster-dictinary.net. Retrieved September 26, 2021, from www.webster-dictionary.net/definition/interview Miller, W. R., Baca, J. C., Matthews, D. B., & Wilbourne, P. L. (2001). Personal values card sort. University of New Mexico. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. Guilford Press. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. Guilford. Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129–140. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford. Millon, T., Grossman, S., & Millon, C. (2015). Millon Clinical Multiaxial Inventory—IV. Pearson Assessments. Moyers, T. B., Manuel, J. K., & Ernst, D. (2014). Motivational interviewing treatment integrity coding manual 4.1. Unpublished manual.

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Prochaska, J. O., & DiClemente, C. C. (2005). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 147–171). Oxford University Press. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. Guilford.

8

Clinical Supervision from a Motivational Interviewing Perspective

Introduction Bernard and Goodyear (2019) defined clinical supervision as an intervention with multiple foci, including to enhance supervisee performance and monitor client welfare. These responsibilities make clinical supervision fundamentally hierarchical and evaluative. Supervisors are empowered to be evaluators and gatekeepers for the profession, whereas supervisees are expected to share personal and clinical concerns and receive feedback from their supervisor on their performance. Given these power dynamics, it seems like a curious choice to use motivational interviewing (MI) in clinical supervision. How can a conversational style rooted in partnership, acceptance, compassion, and evocation be used within a relationship that is so inherently unequal? In this chapter, we argue that there is a place for the guiding and collaborative style of MI in clinical supervision and that supervisors can use MI to help supervisees strengthen their motivation and commitment to engage in effective clinical practice. Clinical supervision is an essential and common practice in clinician mental health settings. Regular individual supervision between a clinician and supervisor is typically supplemented with group supervision as well as informal and unscheduled consultation with more senior colleagues. The quantity of supervision may vary depending on state licensure requirements and the scope of the agency. In a study by Choy-Brown and Stanhope (2018) of clinical supervision in community mental health agencies, participants reported an average of approximately two hours of supervision per week. These authors found that the amount of time spent in supervision varied based on the intensity of services provided by the participant’s agency (e.g., participants within agencies that offered Assertive Community Treatment reported more time in supervision compared to those working in outpatient settings; Choy-Brown & Stanhope). Supervision should primarily serve a clinical function focused on case conceptualization and therapeutic interventions; however, it is not uncommon for clinical supervision to also include discussion of nonclinical content, such as administrative tasks and case management (Schriger DOI: 10.4324/9781351244596-10

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et al., 2021). Given its format and primary focus, supervisors can use MI within clinical supervision settings to evoke and strengthen supervisee motivation related to delivery of clinical services. The chapter begins with an exploration of how MI can be used in clinical supervision. More specifically, we examine the similarities between MI and several of the clinical supervision best practices adopted by the Association for Counselor Education and Supervision (ACES, 2011). We then explore how MI fits with several common models of clinical supervision, including the Integrated Development Model (IDM; McNeill & Stoltenberg, 2016), Bernard’s (1979, 1997) Discrimination Model, and cognitive behavioral supervision (Newman & Kaplan, 2016). Next, we discuss some of the differences between using MI in counseling and clinical supervision. Using MI within the structure and functions of clinical supervision is discussed. This is followed by a description of several MI-informed strategies, across the core MI processes of engaging, focusing, evoking, and planning, that supervisors can use to build motivation among supervisees during clinical supervision. We conclude with a case study illustrating how MI can be used to address supervisee ambivalence to change. Motivational Interviewing as a Clinical Supervision Approach Few authors have explored the intersection between MI and clinical supervision. When MI has been discussed, it mainly has been applied to specific supervisory issues, such as parallel process (Giordano et al., 2013) and resistant behaviors (Wahesh, 2016) as well as improving clinician MIadherent behaviors (Martino et al., 2006). Clarke and Giordano (2013), however, presented MI as an approach that clinical supervisors can use to address the essential aspects of clinical supervision, including establishing and maintaining the working alliance, enhancing motivation, and delivering corrective feedback. Further, inspection of the ACES (2011) best practices guidelines indicates that the core relational and technical elements of MI can be used to support the structure and processes of clinical supervision. There are several parallels between the best practices in clinical supervision adopted by ACES (2011) and MI. Similar to the engaging process in MI, clinical supervisors are encouraged to form and maintain a strong working alliance with their supervisees. Establishing a safe and supportive environment promotes trust and can alleviate evaluative and performance anxiety experienced by the supervisee (ACES, 2011). As in the focusing process of MI, goal setting in clinical supervision should be collaborative in nature, and when feedback is provided by the supervisor, it should be chunked, or communicated in manageable amounts during the session (ACES). Clinical supervisors are encouraged to find ways to support supervisee self-efficacy in supervision (ACES), an important task

134 Applications of MI in CMH Settings in the evoking process in MI. Further, as in MI, the concept of resistance is understood not as a pathological trait of the supervisee, but as a normal response to change that can be influenced by the clinical supervisor’s actions (ACES). In addition to these areas of common ground, there also are several ways MI can enhance supervisor implementation of the best practices guidelines. According to ACES (2011), clinical supervisors should help supervisees process feedback given in supervision; however, no guidance is provided on how this processing should occur. It is possible that some approaches to processing feedback could potentially deepen the supervisee’s ambivalence around engaging in change (e.g., emphasizing the supervisee’s negative self-talk related to corrective feedback). On the other hand, MI can be used to process feedback in a manner that increases supervisee importance, confidence, and commitment to change. Another opportunity for MI relates to the practice, “The supervisor chooses interventions that will help the supervisee work toward his/her learning goals” (ACES, 2011, 4.c.iv). Supervisors can use MI in cases where personal motivation, rather than knowledge or skills, keeps the supervisee from engaging in effective clinical practice. Finally, although the best practice guidelines define resistance in clinical supervision, little guidance is provided on how to manage it, “The supervisor deals with supervisee resistance in productive ways, using culturally appropriate strategies to guide, challenge, and encourage supervisees” (ACES, 5.b.iii). Using MI, supervisors can reduce discord within the working relationship and soften supervisee sustain talk related to supervisory goals.

How Does Motivational Interviewing Fit Within Common Supervision Models? Bernard and Goodyear (2019) organized the various models of clinical supervision into three broad categories. Psychotherapy-based models utilize counseling theories to understand supervision and determine supervision interventions. Developmental models consider the supervisee’s training and experience when determining the processes, goals, and structure of supervision. Finally, process models provide supervisors with a framework for understanding the context and tasks of supervision. These models also offer guidance on how to organize interactions in session. To provide effective clinical supervision, supervisors should use all three kinds of supervisory models (Bernard & Goodyear, 2019). We provide an overview of how MI fits with the most popular and wellresearched models within each category: McNeill and Stoltenberg’s (2016) Integrated Developmental Model (IDM), Bernard’s (1979, 1997) Discrimination Model, and cognitive behavioral supervision (Newman & Kaplan, 2016).

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IDM According to McNeill and Stoltenberg (2016), clinicians progress through four developmental levels: Level 1 (beginning); Level 2 (intermediate); Level 3 (advanced); and Level 3i (integrated). Changes in three supervisory structures including motivation, autonomy, and self-other awareness across multiple clinical competencies signal progress through these stages. Level 1 clinicians are highly motivated to develop professional competence, they require a significant amount of structure in supervision, and can be overly focused on themselves. This self-preoccupation often results in confusion and anxiety and makes it difficult to be fully present with clients in session. Level 2 clinicians function with more independence, which can lead to supervisee–supervisor conflicts. Further, their motivation fluctuates between being extremely confident to lacking confidence. Unlike Level 1 clinicians, they are able to be present with their clients; however, they sometimes they overidentify with them. Level 3 clinicians have stable motivation, are mostly autonomous as they transition into independent practice. Additionally, they are able to focus on and empathize with their clients, while maintaining self-awareness of their own cognitive and affective reactions. Level 3i clinicians have developed their own individualized approach to counseling, have high and stable intrinsic motivation, and have mastered the various domains of counseling practice, including clinical assessment, treatment planning, case conceptualization, and counseling interventions (McNeill & Stoltenberg, 2016). Supervisory techniques should be chosen on the basis of the supervisee’s developmental level. McNeill and Stoltenberg (2016) described five types of supervisor interventions that can be used strategically to address supervisee needs across the four developmental stages. Facilitative interventions communicate support and encouragement to the supervisee. These interventions are especially important to use with Level 1 clinicians to reduce their anxiety, and with Level 2 clinicians when disagreements occur (McNeill & Stoltenberg, 2016). Providing concrete advice and direction are considered prescriptive interventions and are to be used more frequently with Level 1 clinicians as these clinicians require additional structure. Conceptual interventions help supervisees understand how case conceptualization, diagnosis, and treatment planning are related. Conceptual interventions are especially helpful with advanced Level 1 and Level 2 clinicians, as these supervisees become more focused on the client and less preoccupied with themselves (McNeill & Stoltenberg). Confrontive interventions highlight discrepancies between counselor actions, emotions, and/or attitudes. These interventions are recommended for use with supervisees who are not as anxious and have increased clinical confidence (e.g., Level 2; McNeill & Stoltenberg). Finally, catalytic interventions help supervisees identify their blind spots as clinicians by probing, exploring, and raising issues. Focusing attention

136 Applications of MI in CMH Settings to the supervisee’s affective or cognitive experience while viewing a particular moment in a recorded counseling session is an example of a catalytic technique to increase the supervisee’s self-other awareness. Given the supervisory structures and interventions outlined within the IDM, there appear to be multiple opportunities for supervisors to embody MI Spirit in clinical supervision. Conveying the qualities of affirmation and absolute worth can be a powerful facilitative intervention to reduce Level 1 clinician evaluative and performance anxiety. Further, supervisor use of accurate empathy can validate the confusion and distress experienced by beginning clinicians. Affirming supervisee strengths, efforts, and attributes help strengthen self-efficacy, which is an important area of supervisory focus with Level 1 and Level 2 clinicians. When appropriate, respecting supervisee autonomy can help strengthen the working alliance when supervising more advanced clinicians. A guiding style of communication consistent with MI Spirit might be contraindicated for Level 1 clinicians because these supervisees are dependent upon their supervisor and need direct instruction; however, evoking can be done with more advanced supervisees as a conceptual intervention to connect theory to practice, or as a catalytic intervention to explore issues of countertransference in session. Finally, approaching confrontative interventions with a sense of curiosity and mutual respect consistent with MI Spirit can help reduce discord and maintain the working alliance. In addition to the various ways that MI Spirit fits within the IDM, MI also can be used as an intervention to address supervisee motivation to change. According to McNeill and Stoltenberg (2016), it is not uncommon for Level 1 and Level 2 supervisees to experience intense fears and doubts about their clinical performance. These concerns can contribute to ambivalence related to trying out new clinical skills that can enhance their effectiveness with clients. Indeed, fear of failure can be a powerful justification to avoid trying something new. Obviously, this can be problematic if the supervisee is engaging in behaviors that are producing less than desirable clinical outcomes. When exploring areas of growth with supervisees who are ambivalent to change, supervisors can use MI to strengthen motivation and commitment to change while maintaining the working alliance and supporting supervisee autonomy. How might it look to use MI after providing feedback on a problematic behavior to a supervisee? Rather than making the arguments to change yourself, start by exploring the supervisee’s reaction to the feedback. Engaging allows you to identify the values, beliefs, and emotions that define the supervisee’s ambivalence. It also increases supervisee autonomy and self-awareness, which are essential for clinician growth. Once you have a better understanding of both sides of the ambivalence, it is important to clarify that the supervisee understands what specific changes must be made. After focusing, you then evoke and strengthen the supervisee’s arguments for change. Encouraging elaboration of change

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talk reduces ambivalence and strengthens determination to change. This should be followed by planning next steps in applying the feedback, with special attention given to strengthening mobilizing change talk and preparing for potential obstacles in implementing the plan. Not spending enough time and attention on the “how” of change can potentially interfere with positive supervisee development as failure in enacting supervisory goals can heighten self-preoccupation, reduce confidence, and create dissatisfaction in supervision. Discrimination Model Bernard’s (1979, 1997) Discrimination Model is a process model that provides clinical supervisors with guidance on how to effectively interact with supervisees in session. The model is comprised of three foci of supervision and three possible supervisor roles (Bernard & Goodyear, 2019). The three foci of supervision are intervention skills, conceptualization skills, and personalization skills. Intervention skills refer to what the supervisee does in session, including the supervisee’s use of specific counseling techniques that are observable to the supervisor. How a clinician thinks about counseling and client issues represents the conceptualization skills foci. This area of focus also includes the clinician’s decision-making process in selecting counseling interventions with clients. Personalization refers to supervisee awareness of how countertransference, cultural bias, and other personal issues impact case conceptualization and in-session behaviors with clients. Lanning (1986) added a fourth foci, professional issues, that refers to supervisee adherence to ethical, legal, and professional expectations. These foci can be addressed by the supervisor from each of the three supervisory roles: teacher, counselor, and consultant. When acting as a teacher, the supervisor provides instruction, gives feedback, or models a specific counseling skill with the supervisee. Supervisors take on the role of counselor not to become the supervisee’s actual counselor, but to use their counseling skills to increase supervisee reflectivity (Bernard & Goodyear, 2019). In describing the counselor role, Borders and Brown (2005) argued that supervisors can use counseling skills to “understand, motivate, and relate to the supervisee” (p. 9). Consultant is more collaborative than the roles of teacher and counselor (Bernard & Goodyear) and is typically assumed when the supervisor determines that it is appropriate for supervisees to trust their own clinical insights and act more independently. These roles provide guidance on how supervisors can help supervisees “create change” (Borders & Brown, 2005, p. 10) across the areas of supervisory focus. Supervisors should be prepared to address all areas of focus using all three roles; however, Borders and Brown (2005) argued that some roles are more suitable for certain foci (e.g., counselor role to address personalization skills).

138 Applications of MI in CMH Settings The Discrimination Model is situation specific (Bernard & Goodyear, 2019), meaning that supervisors might move in and out of the various roles to address different areas of focus within the same session. In situations where supervisee ambivalence is the focal point of supervision, MI can be blended with the Discrimination Model to increase the supervisee’s intrinsic motivation to change. MI seems like an obvious choice to address supervisee ambivalence to changing particular intervention skills; however, MI also can be an option to address motivation to change related to other supervisory foci, such as conceptualization (e.g., increasing supervisee confidence in using a different theoretical lens to understand client issues), personalization (e.g., enhancing motivation related to being open to experiencing and processing affective reactions in supervision), and professional issues (e.g., increasing supervisee perceived importance to follow professional guidelines). Acting in the counselor role, supervisors can use their counseling skills to explore ambivalence, clarify the specific target change, and evoke change talk before transitioning into the planning process. Consistent with Bernard’s (1979, 1997) definition of the counselor role, supervisors using MI promote supervisee self-reflection, except that there is an intentional emphasis placed on activating motivation and resources while processing the supervisee’s internal experiences. Addressing the processes of engaging, focusing, and evoking ahead of planning next steps can strengthen supervisee motivation and commitment to address the particular supervisory goal. What if the supervisee does not follow through with the agreed upon plan? The supervisor can shift into the role of teacher to provide direct feedback on the consequences associated with the supervisee’s performance. In addition to being a natural fit to use while in the role of counselor, elements of MI can be applied to the roles of teacher and consultant and can inform the general practice of supervision when using the Discrimination Model. For example, supervisors acting as teacher can use elicit-provide-elicit (Miller & Rollnick, 2013), offer instruction in a collaborative way that supports autonomy, increase engagement, and draws out the wisdom of the supervisee. MI spirit also can be a helpful framework for supervisors to consider when acting as consultant. Although supervisors may wish to take a neutral stance as consultant (i.e., not guiding the supervisee in a particular direction), partnership, acceptance, compassion, and evocation are important qualities to convey when the goal is to empower supervisees to trust their judgment and act autonomously. Finally, MI spirit, particularly compassion and acceptance, can serve as a reminder to supervisors that supervisory roles and foci should be determined based on the best interests and individualized needs of the supervisee and not simply out of familiarity or comfort.

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Cognitive-Behavioral Supervision As with other psychotherapy-based models of supervision, cognitive behavioral supervisors seek to teach their supervisees the concepts and strategies associated with the specific theoretical orientation. This includes teaching supervisees the methods of CBT (e.g., agenda-setting, self-monitoring, guided discovery, and assigning homework) and how to “think like CBT practitioners” (Newman & Kaplan, 2016, p. 21) in applying cognitive behavioral theory to case formulation and treatment planning. Although cognitive behavioral supervisors do not provide counseling to the supervisee, there are several similarities between CBT counseling and supervision. According to Newman and Kaplan (2016), both CBT counseling and supervision should occur within a safe and collaborative environment that promotes self-efficacy and hopefulness. Teaching skills, offering feedback, and measuring outcomes are some other features that CBT counseling and supervision have in common (Newman & Kaplan). Cognitive behavioral supervisors apply the techniques used in CBT to facilitate supervisee learning. Cummings et al. (2015) outlined three core processes of CBT supervision: (a) setting an agenda for each supervision session, (b) encouraging supervisees to engage in problem-solving and generate their own ideas before providing feedback, and (c) providing ongoing formative positive and corrective feedback on supervisee performance. As a result, the format of a typical CBT supervision session includes agenda-setting, review of the supervisee’s caseload, and discussion of CBT-related topics, such as case formulation and delivery of CBT techniques (Newman & Kaplan, 2016). In session, supervisors may use a variety of strategies to support supervisee professional development including providing didactic instruction, viewing recordings of the supervisee’s clinical work, reviewing data collected via routine outcome monitoring, active learning strategies (e.g., rehearsal and role play), and assigning homework. Through the combination of didactic and experiential learning, supervisees develop a deeper understanding of cognitive behavioral theory and techniques, which translates to more competent use of these strategies in counseling and better client outcomes. As in CBT, MI can be integrated into cognitive behavioral supervision to strengthen motivation and commitment to change. A growing body of literature suggests that CBT combined with MI outperforms CBT alone in improving clinical outcomes (Marker & Norton, 2018; Randall & McNeil, 2017; Romano & Peters, 2015). Researchers have speculated that MI enhances CBT in several ways, such as by strengthening the therapeutic relationship, reducing clinician-client discord, and addressing ambivalence in relation to learning new cognitive-behavioral skills (Naar & Safren, 2017). Thus, it seems wise for supervisors to blend MI into cognitive behavior supervision to support supervisee engagement and learning.

140 Applications of MI in CMH Settings One way this can be done is by delivering MI as an initial supervisory intervention to bolster supervisee intrinsic motivation to engage in the didactic and experiential aspects of clinical supervision. Early in supervision, supervisors can use scaling questions to assess their supervisees’ perceptions of the importance of past supervision experiences and confidence in using CBT skills and theory; supervisors then can evoke supervisee arguments related to engaging in supervision moving forward to improve clinical practice and client outcomes. Another way that MI can be integrated into CBT is for supervisors to use motivational strategies when discord (e.g., supervisee–supervisor disagreement) or ambivalence (e.g., supervisee indicates a lack of confidence in using a clinical behavior) occur. During these times, MI can promote supervisor-supervisee collaboration, an essential element of cognitive behavioral supervision (Newman & Kaplan, 2016), while also motivating supervisees to participate in supervision, respond to supervisor feedback, or practice new clinical behaviors. Once the supervisee’s ambivalence has been resolved, the supervisor can shift back into the action-oriented style of CBT and cognitive behavioral supervision. Differences Between MI Counseling and MI Supervision Counseling and clinical supervision have several similarities and differences. Both counseling and clinical supervision can involve addressing the recipient’s unhelpful behaviors, cognitions, and emotions; however, the goal of therapeutic work in clinical supervision is to increase the clinical effectiveness of the supervisee (Bernard & Goodyear, 2019). MI can be useful in helping supervisees change clinical behaviors (e.g., management of countertransference, use of specific clinical skills) that hinder client care. Unlike counseling, clinical supervision is an educative intervention that has three separate yet related aims of facilitating clinician professional development, ensuring competent client care, and gatekeeping for the profession. This highlights another key difference, which is that clinical supervision is evaluative and hierarchical in nature (Bernard & Goodyear). Supervisors must consider these differences when determining how to use MI in clinical supervision. Given the power dynamics within the supervisory relationship, supervisors should be cognizant of the ethical issues associated with using of MI to facilitate supervisee change. First and foremost, MI should only be used to advance the best interest of the supervisee. When it is unclear if it is in the supervisee’s best interest to change, the supervisor should take a neutral stance and avoid selective reinforcement of a particular side of change. Relatedly, supervisors should consider how their own interests might be affected by change. In exploring these kinds of dilemmas in organizational leadership, Marshall and Nielsen (2020) argued that leaders should exercise caution when employee change affects their own

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interests. Further, the more that a leader has to gain from the employee’s change, the less appropriate it is to use MI (Marshall & Nielsen, 2020). We believe that MI can be used when change benefits both the supervisor and supervisee; however, supervisors should be aware of their personal biases and exercise caution to ensure that they focus only on the benefits of change for the supervisee. MI is a clear choice as a supervisory intervention when addressing ambivalence related to counseling or case conceptualization skills because changes in these areas benefit the supervisee. Enhancing supervisee clinical effectiveness may have some secondary benefits for the supervisor, but the primary beneficiary of change is the supervisee. Situations can arise in supervision when MI is not appropriate because change benefits the supervisor and not the supervisee. Years ago, I (EW) had a supervisee who was finishing her clinical field experience and had to decide whether to remain in my department or transfer to a new site in the fall. She had been an outstanding staff member and training someone new can be very time consuming, so it was in my best interest for her to stay; however, it was not necessarily in her best interest to remain in my department. In fact, there are many good reasons for counseling interns to take on different placements during their clinical training. Given this dilemma, I did not use MI when discussing this issue. Instead, I was upfront about my bias when we discussed her options, and I encouraged her to speak her other mentors, including her academic advisor, to help her make a decision that best aligned with her personal and professional goals. The evaluative nature of clinical supervision poses another potential challenge for supervisors who wish to use MI. Some supervisees may withhold information related to difficult client cases or their experiences in clinical supervision out of fear of receiving an unfavorable evaluation (Bernard & Goodyear, 2019). Within the context of MI, these supervisees may not disclose sustain talk related to a target change or offer dubious change talk to appease the supervisor. Fortunately, there is convincing evidence that developing a strong working alliance helps reduce instances of nondisclosure in supervision (Gibson et al., 2019; Hutman & Ellis, 2020). Therefore, compared to the use of MI in counseling, greater attention should be devoted to the engaging process in supervision to create safe, respectful, and collaborative relationships that minimize hierarchy and power differentials between supervisor and supervisee. As a matter of fact, we suggest that supervisors view supervisees as the equivalent of clients who are mandated to counseling. This comparison is not meant to belittle supervisee intrinsic motivation to engage in supervision; instead, it reflects the nature of most supervisory relationships (i.e., supervisees usually do not have a choice in taking part in supervision or selecting their supervisor) and underscores the importance of reflective listening to convey understanding and accurate empathy to strengthen supervisee engagement.

142 Applications of MI in CMH Settings Also essential for effective practice of MI in clinical supervision is supervisor transparency. Before evoking change talk, supervisors should be clear about their hopes and aspirations for the supervisee (e.g., to become better at using a particular skill) as well as their intentions to influence supervisee behavior (e.g., “would it be okay if we spent some time now exploring some of your top arguments for making this change?”). There are several reasons why transparency in using MI is important in clinical supervision. Clinical supervision is a learning intervention; therefore, supervisor genuineness pertaining to supervision goals and evoking change is effective modeling of MI Spirit. Further, awareness of the deliberative process involved in using MI can help supervisees develop their own mental framework for determining when and how to use MI with their clients. Another reason it is important for supervisors to disclose their use of MI is that without full transparency, supervisees might interpret the guiding style of MI as a form of covert influence or manipulation to gain compliance. This is an important consideration in clinical supervision compared to counseling because it is more common for session agenda items and target changes to be brought up by the supervisor in clinical supervision, than by the clinician in counseling. A final issue to consider when deciding whether to use MI is the duty of the supervisor to monitor the quality of client services. Two important features of MI counseling: autonomy support and shared agenda setting, are not practiced to the same extent with supervisees because supervisors are responsible for ensuring client care. Supervisors should use a directing style of communication when supervisees display behavior that jeopardizes client well-being (e.g., a supervisee fails to assess for suicidal ideation when it was clearly warranted). This includes pointing out problematic behavior and outlining the steps that the supervisee must take to address the concern. Similar to situations in counseling where a client is in danger, a directing approach should be used regardless of the supervisee’s motivation to address the issue. Once corrective feedback is communicated, the supervisor can shift to a guiding style that is consistent with MI to evoke the supervisee’s own arguments and resources for addressing the feedback. What is critical to remember is that supervisors should be prepared to shift flexibly among the three different communication styles of following, guiding, and directing to address the core responsibilities of clinical supervision. Motivating Interns and Counselors Through Supervision Thus far, we have focused mainly on the why of using MI in clinical supervision. We argued that MI is an appropriate strategy for supervisors to use to motivate supervisees. We also explored the fit and potential use of the core relational and technical elements of MI across three popular clinical supervision models. Lastly, we described several key differences

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between clients and supervisees that supervisors should be mindful of when deciding whether to use MI. Now, we will discuss the how of applying MI in clinical supervision by presenting strategies for engaging, focusing, evoking, and planning with supervisees. Engaging The primary aims of the engaging process in clinical supervision are to nurture the working alliance and develop a deeper understanding of the supervisee’s perspective. Without a strong working alliance, it is impossible to have an honest conversation about change. Supervisors can cultivate a supervisory relationship based in trust and respect by conveying accurate empathy, warmth, and autonomy support. In addition, supervisors should show genuine curiosity and interest in the supervisee. Thus, the primary strategy when engaging is reflective listening, rather than factgathering or communicating information. When sensing ambivalence, it can be easy for supervisors to slip immediately into “fix-it mode” and try to solve the problem for the supervisee using a directing style. Instead, supervisors should explore both sides of change using open-ended questions (e.g., “Where do you stand related to this goal?”) and reflections (e.g., “You are hesitant try something new and you recognize that your current approach with this client is not paying off as you had expected.”). It may sound counterintuitive to explore arguments against making a change that is in the best interest of the supervisee; after all, supervisors have a duty to promote supervisee development and evoking this kind of sustain talk may signal to the supervisee that the supervisor is on the side of the status quo. Then again, recognizing that ambivalence is normal is not the same as agreeing that change is impossible. Further, acknowledging that change is difficult validates the experience of the supervisee, which can strengthen the working alliance. Exploring sustain talk also helps determine the degree to which perceptions about the importance of and confidence in making the change contribute to the supervisee’s ambivalence. Understanding how importance and confidence factor into ambivalence can inform how the supervisor tackles the focusing and evoking processes later. Engaging also is fertile ground from which the supervisee’s own arguments for change come to light. The most meaningful pro-change arguments often are related to one’s values, goals, and strengths. Careful attention to identifying and acknowledging these attributes helps the supervisor understand what truly motives the supervisee. For example, altruism can be a powerful motivator for supervisees who must change deep-rooted habits to become better clinicians. Increased awareness of values, such as altruism and benevolence, can ignite supervisee change. Sometimes values also can contribute to maintaining the status quo; indeed, achievement striving can be a double-edged sword in that it can potentially intensify

144 Applications of MI in CMH Settings ambivalence when supervisees fear not being successful at a new behavior. Once a clear and full understanding of the ambivalence has emerged, the supervisor can collaborate with the supervisee in determining the direction of the change conversation. Focusing Focusing involves clarifying the specific change target. This process usually requires some negotiation as supervisors try to balance the supervisee’s interests with their own priorities. Determining the direction in a collaborative way helps maintain the working alliance established during the engaging process and ensures that the specific change identified is meaningful to the supervisee. Supervisors can seek collaboration by eliciting and exploring supervisee ideas before offering their own suggestions and, whenever possible, deferring to supervisee preferences. In situations when the supervisor has a potential focus that is not shared by the supervisee, priority should be given to discussing the supervisee’s areas of focus. I (EW) once had a supervisee who began internship with several goals that she developed with her previous supervisor in practicum. These goals reflected important areas of professional growth that the supervisee needed to address during internship. When we met to discuss her plans for internship, she did not bring up these goals; instead, she shared some new goals that she wanted to work on during internship that were unrelated to what she had discussed with her previous supervisor. Rather than insisting that we focus on the goals from practicum, I gently reminded her of these goals and suggested that we wait to talk about them until after we had reviewed the new goals that she created for internship. This communicated partnership and led to a richer and more collaborative discussion of her practicum goals later in the session. This process would change, though, in situations where the supervisee was clearly harming a client. When client safety is a concern, the supervisor should use a more directive approach in communicating goals or possible areas of focus to the supervisee. When there is more than one possible direction to go, supervisors should help supervisees select the most reasonable and meaningful focus to address first. This involves the supervisor empowering the supervisee to explore and prioritize each option, rather than deciding the change focus for the supervisee. Having more than one possible direction to go in can be a good thing (i.e., if one strategy does not work out there are other options to choose from); however, entering the evoking process with multiple foci can muddy the water. It can cause the supervisor and supervisee to splinter off in different directions if the supervisor evokes change talk related to one change target while the supervisee considers another focus. In these situations, it is essential that supervisees chart out all possible directions to determine where they can begin. Options that

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are not identified as immediate areas of focus can be revisited later in supervision. One way that supervisors can facilitate this process of selfexploration is by using an agenda map to examine the importance and impact of each possible change focus (see Chapter 4). There are times when providing supervisees with information or advice can clarify the focus. When the focus is unclear, strategic use of advicegiving or offering information can help the supervisee determine how to move forward. This should be done in an intentional way that supports autonomy and seeks collaboration. Information or advice should not be given until a thorough exploration has been conducted of the supervisee’s own ideas or understanding. Further, the goal of providing information should be to address gaps in supervisee knowledge or self-awareness, not to demonstrate supervisor expertise or exert power within the relationship. Supervisors can prevent information sharing from turning into confrontation or persuasion by emphasizing that it is the supervisee’s choice to decide what to do with the information offered, and when offering suggestions, providing more than one option for the supervisee to consider. For instance, instead of providing one option for improving a specific clinical behavior, offer two to three different strategies. When appropriate, supervisors can support autonomy by asking permission before providing information or advice. After sharing the information, supervisors should elicit supervisee perceptions of what was provided using open-ended questions (e.g., “Which ideas interest you the most?”) to promote engagement and self-reflection. Evoking Once a focus is determined, supervisors use open-ended questions, affirmations, reflections, and summaries (OARS) to guide supervisees in the direction of change. More specifically, supervisors use their OARS in an intentional way to draw out and selectively reinforce supervisee language that favors change (Miller & Rollnick, 2013). Eliciting and encouraging elaboration of change talk increases the perceived salience and value of the target change. At the same time, it promotes a reevaluation of the perceived barriers of change and advantages of the status quo (i.e., sustain talk) that make up the other side of the ambivalence. The goal of the evoking process is to tip the balance of the ambivalence in favor of change by helping supervisees connect (or sometimes reconnect) in a deep and meaningful way with their best arguments for change. This generates momentum to enact change and makes the potential obstacles and disadvantages associated with moving away from the status quo seem more manageable. Supervisees are more likely to make the change when they perceive the change as being important. For that reason, it can be helpful to use evocative questions and reflections to encourage supervisees to articulate and

146 Applications of MI in CMH Settings explore their desire, reasons, and need to change. Examples of evocative questions that elicit importance talk include: • • •

What do you hope this change will accomplish? (desire) What is your best reason for making this change? (reasons) Why is it necessary to make this change now? (need)

Supervisors can respond with questions that seek elaboration (e.g., “tell me more”) or continue exploration (e.g., “what is another reason for making this change?”) to keep the conversation moving toward change. It also helps to respond with refections that restate (i.e., simple refections) or add something to what the supervisee said (i.e., complex refections). Refections provide a chance for supervisees to hear again, sit with, and ponder what they said. Refective statements that connect change and supervisee values are particularly useful at strengthening motivation and commitment to change. These refections help supervisees understand change as something that is ego-syntonic, or compatible with how they view themselves, which can create greater discomfort related to maintaining the status quo. Offering individualized feedback is another strategy that can increase perceived importance to change. In counseling, feedback would typically include personal assessment results and information comparing client behaviors to a norm group (e.g., other U.S. adults or adolescents). In clinical supervision, the assessment data originate not from the supervisee but from the supervisee’s caseload. Results from routine outcome monitoring tools that collect client feedback on treatment progress, such as the Outcome Rating Scale (Miller & Duncan, 2004) or Outcome Questionnaire-45.2 (Lambert & Burlingame, 1996), can help supervisees recognize the disadvantages associated with the status quo. Both assessments provide scoring cut-offs for normal client functioning and reliable change over time, which combine to signify clinically significant change. When supervisees are ambivalent about trying a new clinical intervention or approach, concrete evidence of client deterioration or stagnation can serve as a powerful wake-up call that change is needed. In a similar way, data collected using measures of therapeutic alliance (e.g., Session Rating Scale; Miller & Duncan) can provide feedback to supervisees on the benefits of changing the way they engage personally with clients in session. Providing feedback in supervision can easily elicit supervisee anxiety and discomfort; therefore, it is essential that it be presented in a neutral, respectful, and collaborative way to support autonomy and make possible an honest appraisal of the information by the supervisee. Supervisors should evoke and strengthen change talk that increases supervisee confidence in making the change. Without perceiving that they have the ability to enact change, supervisees will likely remain in a chronic state of ambivalence. We have found this to be true even

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when perceived importance is high. Evocative questions targeting ability change talk help supervisees clarify how they can make the change (e.g., “which change strategy is most possible?”) and identify the internal and external resources that can be utilized to support the change process (e.g., “how might you make this change?”). These questions help supervisees envision change and bring them one step closer to action. As with evoking importance talk, it is critical that supervisors respond to supervisee change talk with questions and reflective statements that encourage exploration and elaboration. Another strategy for increasing confidence is to affirm strengths and efforts. Affirmations are a simple yet powerful way for supervisors to help supervisees recognize that they have what it takes to change. Along with these strategies, reframing setbacks in the change process as learning experiences can help maintain confidence and keep the supervisee from experiencing discouragement. Planning Planning should begin once the supervisee has made the decision the change. A clear sign that supervisees have mostly resolved their ambivalence and are ready to begin planning is when they make statements that imply action or readiness to change. This includes mobilizing change talk related to commitment, activation, and taking steps to change. Supervisors should check to see if the supervisee is ready to begin planning even when these statements are relatively low in strength (e.g., rather than making a strong declaration of change, the supervisee says something to the effect of “I guess I should do this”). A helpful strategy for determining whether to move on from evoking is for the supervisor to summarize the most significant change talk and end the summary with a pointed question that is meant to move the conversation forward into action planning (e.g., “what’s next?” or “where do we go from here?”). If the supervisee’s response signals a desire to transition from talking about the why of change to the how of change, planning is warranted; however, if the supervisee responds with sustain talk, more evoking is needed. It also may be necessary to revisit the tasks of the engaging and focusing processes, as effective planning in MI is not possible without significant engagement, a clear and shared goal, and sufficient motivation to change (Miller & Rollnick, 2013). The two main tasks of the planning process are to strengthen commitment to change and develop a change plan. Supervisors can help supervisees consolidate their commitment to change by evoking and seeking elaboration of ability, commitment, and activation change talk. Attending to confidence and mobilizing change talk helps bolster and deepen one’s intention to change. Like focusing, planning for change should be a collaborative process that involves the supervisor evoking (rather than instilling) the specific elements of the plan. Action planning should

148 Applications of MI in CMH Settings always address the what, why, how, when, where, and who of change. Possible questions to explore each of these dimensions include: • • • • • •

What: What are your specific change goals? Why: What are your most important arguments for making the change? How: What concrete steps will you take to implement change? When: What is the timeline for making this change? Where: Where will the change take place? Who: Who can help you make this change?

To increase the likelihood of success, each component of the plan should be solidifed before the supervisee tries implementing it. Planning also should involve helping the supervisee identify the signs that the plan is working. This helps with monitoring progress and, when goals are achieved, can provide a boost of confdence to the supervisee. Finally, planning in MI is incomplete without some exploration of the potential barriers that can interfere with the plan. Anticipating and trying to address these barriers in advance via problem-solving acknowledges the reality that change is diffcult and helps consolidate commitment by increasing supervisee self-effcacy. Over time, commitment should be revisited and reinforced, and the change plan modifed based on observed progress and any unforeseen obstacles that arise. We now turn to seeing what MI in clinical supervision might look like. In the proceeding case study, MI is used by a clinical supervisor to increase supervisee motivation to utilize a specific clinical strategy with clients.

Case Study The following case example illustrates the use of MI in clinical supervision. The case is fictional; however, it is drawn from the second author’s experiences as a clinical supervisor. The supervisee, Emma, is a 23-yearold White cisgender female beginning her internship in clinical mental health counseling (CMHC). Emma is an outpatient therapist at a community behavioral health clinic where she uses CBT with adult and adolescent clients. This is the same agency where she completed her counseling practicum during the previous academic year. The exchange below is from an early session between Emma and her new clinical supervisor. During the session, Emma and her supervisor discuss the Revised Cognitive Therapy Scale (CTS-R; James et al., 2001) to explore possible learning goals for internship. The CTS-R is a rating scale that measures counselor competence in delivering cognitive therapy, thus making it a valuable tool for identifying strengths and areas of growth in cognitive behavioral therapists. As they review the CTS-R together, Emma

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expresses some hesitation related to the CBT competency: assigning and reviewing client homework in therapy. SUPERVISOR:

You have concerns about your ability to use homework with clients. (Complex reflection) EMMA: I know that homework is important, but I had some trouble with it in practicum. Sometimes my clients wouldn’t do what we had planned. When that would happen, I would give up and stop assigning it. SUPERVISOR: So this is an area of CBT practice that you can work on. (Complex reflection) EMMA: I guess so. Some of my clients were very into their homework. Others, not so much. It was easier to assign homework with my adolescent clients. They usually listened to me. But my adult clients, that’s another story. SUPERVISOR: You were successful with your adolescent clients. What’s been a challenge is getting the adult clients on your caseload to follow through with completing homework. (Affirmation, simple reflection) EMMA: Yeah. It is easier with adolescents. Maybe because they are used to doing homework for school or have fewer things going on. Many of my adult clients would say that they were so busy that they would forget. I also wonder if some didn’t take me seriously because I am so young. Or, maybe they don’t think that homework will help. I’m not sure. I’d stop assigning homework with these clients because I assume that they wouldn’t do it. SUPERVISOR: You can think of a lot of reasons why your practicum clients didn’t do their counseling homework. That makes you unsure about using this strategy with your adult clients in internship. (Complex reflection) EMMA: Exactly. SUPERVISOR: EMMA, I am hearing a couple possible learning goals for internship that come to mind. Do you mind if I share them? (Seeking collaboration) EMMA: Sure. SUPERVISOR: During internship, you can try out some new ways of introducing and assigning homework to your clients. Another option is to explore other ways of engaging with clients who do not do their homework. Ultimately these are your goals, so I’m curious to hear your thoughts on my suggestions. (Giving information, emphasizing autonomy) EMMA: I like that idea of setting a goal related to how I assign homework. I think that if I address that issue it would cut down on my need to confront clients who don’t come to session prepared. But, I am not sure what I can do differently. SUPERVISOR: Would it be alright if we took a few minutes to explore this issue more? (Question, seeking collaboration)

150 Applications of MI in CMH Settings EMMA: (Nods SUPERVISOR: I

head). have found that it helps spending time trying to understand what is currently happening before moving directly into action planning. And, exploring this issue will help us identify your best arguments for why and how you can use homework with clients. This is the basis of MI, which is an approach that I use with my clients and supervisees when they are not sure about how to make a change. How does that sound? (Giving information, question) EMMA: I am up for talking more about homework in CBT, I want to get better at using it with my clients. (Change talk—desire) SUPERVISOR: You mentioned earlier that some of your clients were really into their homework. When have you been successful at using homework with your adult caseload during practicum? (Simple reflection, question) EMMA: I can think of a couple of clients who would always do their homework. One really enjoyed the exercises that she would do between sessions. Like, she would come in raving about how the activities—we did a lot of mindfulness practice together—would help her deal with stress. SUPERVISOR: You selected homework that was really meaningful for the client. (Complex reflection) EMMA: Well, we came up with the homework ideas together. She had heard about mindfulness meditation and was interested in trying it out. SUPERVISOR: Ah. So, the homework was something that was meaningful and also was determined in collaboration with the client. How might your experience with this client inform how you use homework moving forward in internship? (Simple reflection, question) EMMA: I can ask my clients what they would enjoy doing or what would be manageable given their schedule. (Change talk—ability) SUPERVISOR: That is a great idea! You mentioned that you had success with a few different clients in practicum. Tell me about some other times when things worked out. (Praise followed by question) EMMA: Another client would put reminders into her phone. SUPERVISOR: That’s interesting. Was that something she did on her own, or did you help her with that? (Question) EMMA: She came up with the idea at first and I would remind her to add the homework -usually it was activity monitoring—into her calendar before we wrapped up each session. SUPERVISOR: You helped her stay on top of completing her homework. (Affirmation) EMMA: Yes. I guess that is something that I can do with my other clients. It definitely won’t work for all of them, but it doesn’t hurt to try. (Change Talk—ability, sustain talk, and low strength commitment change talk)

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You can ask your clients if it would be helpful if they added reminders to their smartphone or calendar. (Simple reflection) EMMA: That won’t work for all of my clients. I know that I tried doing that with some in practicum and it did not help. (Sustain talk) SUPERVISOR: Setting reminders might help with some of your clients. What else can you do increase the likelihood that your clients will do their homework? (Agreeing with a twist, question) SUPERVISOR:

The supervisor determined early in the conversation that Emma’s confidence was the primary cause of her ambivalence and, therefore, concentrated on evoking and strengthening ability change talk. This involved exploring how Emma can incorporate homework more effectively into treatment with her adult clients in internship. Importantly, the supervisor used a strengths-based approach by discussing examples of when Emma was able to use homework with her clients rather than focusing on times when she was unsuccessful. If there had been no successes to discuss, the supervisor could have explored in greater depth why Emma thought homework compliance was low in order to drum up potential new ideas moving forward. Similarly, it would have been appropriate for the supervisor to provide suggestions if Emma had not been able to offer her own strategies to change approach to assigning homework. As the session continues, the supervisor and Emma discuss other strategies that she can use to increase homework compliance. They also explore the possible outcomes of using these new strategies to draw out additional reasons for change. Recognizing these advantages of change also bolster Emma’s perceived need to act. Through evoking, Emma’s confidence increases, and she becomes more committed to trying out these approaches with her clients. Planning involves solidifying the menu of strategies that Emma will use with her clients, clarifying the specifics of the goal (i.e., that Emma will use these new strategies to help facilitate homework compliance with her adult clients in internship), preparing for obstacles, and developing a timeline for implementing and monitoring Emma’s efforts.

Summary Clinical supervisors can use MI to support supervisee learning and professional growth. More specifically, MI can be helpful with supervisees who are ambivalent about changing a particular clinical behavior because of a lack of perceived importance or confidence. Through engaging, the supervisor can explore the supervisee’s hesitancy around change and strengthen the supervisee alliance. Once a clearly defined focus is agreed upon by the supervisor and the supervisee, the supervisor evokes and strengthens the supervisee’s own motivation and commitment to change. This is followed by planning for change, which is a collaborative process that brings to bear the strengths and resources of the supervisee. The use of MI in clinical

152 Applications of MI in CMH Settings supervision is a dynamic process that sometimes necessitates the supervisor shifting out of MI and into a more directive approach based on potential impact of the supervisee’s behavior on the client. Activities and Resources 1. Although not directly related to CMHC, the Center for Substance Abuse Treatment’s (2009) treatment improvement protocol for supervising substance abuse counselors is a valuable resource on how to apply the principles and models of clinical supervision in practice. 2. Develop a list of possible supervisory goals that would benefit from the use of MI. For each goal, create a list of evocative questions that elicit supervisee change talk. 3. Improving your clinical supervision skills: Consider all the different types of information that you provide to your supervisees in clinical supervision (e.g., agency policies, your professional disclosure statement, theoretical concepts, tips on using interventions or techniques). Reflect on how you might deliver this information differently using the concepts discussed in this chapter.

References Association for Counselor Education and Supervision. (2011). Best practices in clinical supervision. Retrieved from www.acesonline.net/wp-content/uploads/2011/10/ ACES-Best-Practices-in-clinical-supervision-document-FINAL.pdf Bernard, J. M. (1979). Supervisor training: A discrimination model. Counselor Education and Supervision, 19, 60–68. http://doi.org/10.1002/ceas.1979.19.issue-1 Bernard, J. M. (1997). The discrimination model. In C. E. Watkins Jr. (Ed.), Handbook of psychotherapy supervision (pp. 310–327). Wiley. Bernard, J. M., & Goodyear, R. K. (2019). Fundamentals of clinical supervision (6th ed.). Pearson. Borders, L. D., & Brown, L. L. (2005). The new handbook of counseling supervision. Lawrence Erlbaum Associates. Center for Substance Abuse Treatment. (2009). Clinical Supervision and Professional  Development  of  the  Substance Abuse  Counselor.  Treatment  Improvement  Protocol  (TIP)  Series  52.  HHS  Publication  No.  (SMA)  14–4435. Substance Abuse and Mental Health Services Administration. Choy-Brown, M., & Stanhope, V. (2018). The availability of supervision in routine mental health care. Clinical Social Work Journal, 46, 271–280. https:// doi.org/10.1007/s10615-018-0687-0 Clarke, P. B., & Giordano, A. L. (2013). The motivational supervisor: Motivational interviewing as a clinical supervision approach. The Clinical Supervisor, 32, 244–259. https://doi.org/10.1080/07325223.2013.851633 Cummings, J. A., Ballantyne, E. C., & Scallion, L. M. (2015). Essential processes for cognitive behavioral clinical supervision: Agenda setting, problem-solving, and formative feedback. Psychotherapy, 52, 158–163. http://doi.org/10.1037/a0038712 Gibson, A. S., Ellis, M. V., & Friedlander, M. L. (2019). Toward a nuanced understanding of nondisclosure in psychotherapy supervision. Journal of Counseling Psychology, 66, 114–121. http://doi.org/10.1037/cou0000295

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Giordano, A., Clarke, P., & Borders, L. D. (2013). Using motivational interviewing techniques to address parallel process in supervision. Counselor Education and Supervision, 52, 15–29. https://doi.org/10.1002/j.1556-6978.2013.00025.x Hutman, H., & Ellis, M. V. (2020). Supervisee nondisclosure in clinical supervision: Cultural and relational considerations. Training and Education in Professional Psychology, 14, 308–315. http://doi.org/10.1037/tep0000290 James, I. A., Blackburn, I. M., & Reichelt, F. K. (2001). Revised cognitive therapy scale (CTS-R). Retrieved from https://ebbp.org/resources/CTS-R Lambert, M. J., & Burlingame, G. M. (1996). Outcome questionnaire 45.2. American Professional Credentialing Services. Lanning, W. (1986). Development of the supervisor emphasis rating form. Counselor Education and Supervision, 25, 191–196. http://doi.org/10.1002/ j.1556-6978.1986.tb00667.x Marker, I., & Norton, P. J. (2018). The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis. Clinical Psychology Review, 62, 1–10. https://doi.org/10.1016/ j.cpr.2018.04.004 Marshall, C., & Nielsen, A. S. (2020). Motivational interviewing for leaders in the helping professions: Facilitating change in organizations. Guilford Publications. Martino, S., Ball, S. A., Gallon, S. L., Hall, D., Garcia, M., & Ceperich, S. (2006). Motivational interviewing assessment: Supervisory tools for enhancing proficiency. Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University. McNeill, B., & Stoltenberg, C. D. (2016). Supervision essentials for the integrative developmental model. American Psychological Association. Miller, S. D., & Duncan, B. L. (2004). The outcome and session rating scales: Administration and scoring manual. Institute for the Study of Therapeutic Change. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. Guilford Press. Naar, S., & Safren, S. A. (2017). Motivational interviewing and CBT: Combining strategies for maximum effectiveness. Guilford Press. Newman, C. F., & Kaplan, D. A. (2016). Supervision essentials for cognitivebehavioral therapy. American Psychological Association. Randall, C. L., & McNeil, D. W. (2017). Motivational interviewing as an adjunct to cognitive behavior therapy for anxiety disorders: A critical review of the literature. Cognitive and Behavioral Practice, 24, 296–311. https://doi. org/10.1016/j.cbpra.2016.05.003 Romano, M., & Peters, L. (2015). Evaluating the mechanisms of change in motivational interviewing in the treatment of mental health problems: A review and meta-analysis. Clinical Psychology Review, 38, 1–12. https://doi.org/10.1016/j. cpr.2015.02.008 Schriger, S. H., Becker-Haimes, E. M., Skriner, L., & Beidas, R. S. (2021). Clinical supervision in community mental health: Characterizing supervision as usual and exploring predictors of supervision content and process. Community Mental Health Journal, 57, 552–566. https://doi.org/10.1007/s10597-020-00681-w Wahesh, E. (2016). Utilizing motivational interviewing to address resistant behaviors in clinical supervision. Counselor Education and Supervision, 55, 46–59. https://doi.org/10.1002/ceas.12032

9

Multicultural Counseling and Motivational Interviewing in the Clinical Mental Health Setting

Introduction Motivational interviewing (MI) has been described as a culturally sensitive counseling approach. Its emphasis on absolute worth, honoring the client’s ideas, compassion, and affirmation makes it well-suited for clients, couples, and families from diverse backgrounds and experiences. Interestingly, the multicultural application of MI has not been discussed as extensively as other aspects of clinical work within previous publications on MI; this chapter will begin to address this gap. We provide an overview of multicultural counseling, the increasingly diverse clientele in mental health agencies, and how MI fits as a culturally sensitive approach. The authors also will explore how MI can be adjusted to work with culturally diverse clients and families, in those instances where a “pure” MI approach may not be the best option. Mental health struggles are an equal opportunity problem, as people across ethnic, racial, gender, and religious lines experience the same devastating effects. However, evaluation, diagnosis, and treatment may have different meanings and interpretations depending on one’s unique background.

The Diversity of Counseling Clientele As the United States population continues to grow more diverse, multicultural counseling competency is essential for proficient practice. Clients who visit clinical mental health agencies are more diverse than ever before. According to the National Institute of Mental Health (2021), in 2019, 33.9% of Hispanics who reported struggling with mental and emotional concerns sought mental health services (either inpatient, outpatient, and/or medication). Just under 33% of African American adults who reported struggling with mental and emotional concerns received mental health services. Among individuals of Asian descent with mental health concerns, 23.3% received services. In comparison, 50.3% of White adults who struggled with mental and emotional concerns received mental health services. These statistics clearly demonstrate growing cultural DOI: 10.4324/9781351244596-11

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diversity in who receives counseling service. And, whereas this trend will most likely continue, we must acknowledge the significant mental health discrepancy among racial groups that continues to exist. For example, American Indian/Alaska Natives, African Americans, Hispanics, and Asian Americans continue to receive treatment at significantly lower rates than non-Hispanic Whites. As education, training, government partnerships, and community resource programs address these disparity issues, clientele among clinical mental health settings will only become more diverse.

Multicultural Counseling: The Fourth Force in Professional Counseling In the early 1980s, a movement within professional counseling responded to the growing diversity within the United States and the acknowledgment that cultural background plays a significant role in mental health. This movement, multiculturalism, has been described as the “fourth force” within professional counseling (Pedersen, 1991; psychodynamic, behavioral, and humanistic being three others; presently, social justice, an extension of multicultural competence, is considered the “fifth force”). Multiculturalism is essential for effective counseling practice. At essence, it is about valuing cultural diversity and understanding culture’s impact on one’s mental health (Chang et al., 2017). It also calls upon mental health counselors to bring cultural sensitivity to their daily clinical practices. For example, mental health theory and diagnosis is grounded in a Western, Euro-American view of what constitutes normal and abnormal behavior. As such, mental health counselors who see clients form different cultural backgrounds may misunderstand behavior that in the dominant culture is labeled as “abnormal.” A counselor who is aware of this potential bias understands that cultural sensitivity and compassion are needed to best help the client, whether that involves a diagnosis or not. The term multicultural counseling generally encompasses two overarching components that reflect (a) mindset and (b) awareness and action. The first, culture-centered counseling (Pedersen, 1995), entails emphasizing the centrality of culture in the counseling process. Here culture takes center stage, and all clinical decisions are made with this mindset. The second, culturally competent counseling (Lee, 2019), is where mental health counselors have knowledge, awareness, sensitivity, skills, and an understanding of multicultural ethical principles and values. A key theme of both components is awareness. Mental health counselors are encouraged to be aware of their own worldview and culture as well as the socio-historical-environmental issues that minority groups have faced, in some cases for generations. Not only do these experiences shape clients’ worldviews, but also can have a strong impact on their mental health. At the same time, it is important that mental health counselors do not adopt a monolithic viewpoint, assuming that all people from a cultural group

156 Applications of MI in CMH Settings adopt a shared perspective (Lee, 2019). As Lee (2019) noted, people from similar backgrounds may share similarities, but each client is a unique individual. An important guideline is to consider the individual within the cultural context, rather than “seeing” individuals as their culture (Lee, 2019). Counselors need to promote a dialogue-friendly environment, work with the unique needs of the client, and be sensitive to cultural struggles and issues, to best assess and counsel mental and emotional problems. Table 9.1 examines multicultural considerations within the typical assessment, diagnostic, and treatment planning process. Incorporating multicultural competency into practice requires a thorough and sensitive cultural assessment, counselor personal awareness, diagnostic and treatment planning collaboration, and culturally sensitive interpersonal skills (White-Kress et al., 2005). A thorough and sensitive cultural assessment might include the following: (a) the client’s worldview, (b) the client’s cultural identity, (c) sources of cultural information to the client, (d) how the client makes meaning of his or her problems/ symptoms, (e) how family and the broader community fit into the picture,

Table 9.1 Multicultural Considerations Throughout the Counseling Process Counseling process

Overarching question

Multicultural considerations

Screening

Is there a possibility the client has a mental health problem?

Assessment

What is the population upon which the assessment is normed?

Diagnosis

Does the client have a diagnosis based on the DSM 5?

Treatment Planning

Is the treatment selected appropriate for the client based on his or her cultural background?

What is acceptable behavior in his or her culture? Do loved ones believe there is a problem? Could there be an instrument bias? How will that impact your interpretation? If using a clinical interview, has the counselor made sure to inquire about cultural views/ perspectives on the problem? Is the counselor’s diagnosis based on sound diagnostic principles, according to objective signs and symptoms, and taking diversity issues into account? How does the client view treatment? What familial and/ or community-based considerations are needed, based on the client’s cultural background?

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and (f) stigmas the client may hold associated regarding mental illness (White-Kress et al.). Counselor personal awareness includes becoming cognizant of their own biases, values, and stereotypes. The importance of this cannot be overstated; failure to recognize one’s underlying cultural perspectives can result in those perspectives being projected onto clients. Multiculturally competent counselors emphasize a key element of the MI spirit: Collaboration. Collaborative treatment and diagnosis include supporting the client’s own understanding, construction, and reality of the problem (White-Kress et al.). In many instances, collaboration with loved ones can be valuable in learning not only more about the client but relevant cultural variables that may need consideration. Finally, the multiculturally competent counselor learns to adjust interviewing style to the cultural norms and preferences of the client (White-Kress et al.). As you will see shortly, the MI interviewing style is well suited for this process. Collaboration is built into the MI ethos, and the MI clinical stance is one of honoring clients and observing that they have valuable and unique perspectives on the topic of behavior change.

Motivational Interviewing as a Culturally Sensitive Counseling Approach Cordisco Tsai and Sebellos-Llena (2020) highlighted a growing body of literature suggesting that adapting MI to the cultural context is critical to its effectiveness with diverse clientele. Cultural adaptation means more than simply respecting one’s culture or being aware that the cultural background of the mental health counselor and client are different. It also entails methodically determining areas of mismatch between an intervention and the client such that the intervention is tweaked or changed to better align with the client’s culture. This change can include surface-level (or surface structure) or deeper, core-level (or deep structure) changes (a description of both surface structure and deep structure is presented later). The result is an intervention that feels emotionally and intellectually connected to client’s values and goals. Of course, there is broad consensus among clinical mental health professionals that consideration of culture is needed for any treatment program; however, despite this awareness, questions remain as to how counselors broadly adapt interventions based on cultural background (Miranda et al., 2005). There is no doubt that MI is having global reach. The Motivational Interviewing Network of Trainers (MINT), a group of individuals who have had training in how to teach MI, have held annual workshops for potential trainers in numerous countries across the world. These workshops attract educators, therapists, and others in the helping professions from Europe, the Middle East, Australia, Asia, South America, North America, and Scandinavia (Wagner & Connors, 2010). According to Lewis (2014), one of the earliest video demonstrations of MI (Miller

158 Applications of MI in CMH Settings et al., 1998) is now produced with translations in Chinese, Italian, Slovenian, French, Portuguese, Spanish, German, and Swedish. Although MI has been successfully translated into several languages, cultural adaptation of the approach has received less attention. The available evidence, however, suggests that culturally adapted versions of MI are more effective than non-culturally adapted versions (we will briefly review some of the empirical evidence later; Cordisco Tsai & Sebellos-Llena, 2020). Given the popularity and explosion of MI within the past couple decades, MI appears here to stay. Its global reach is only bound to expand. The affirming, respectful clinical stance of MI seems to be applicable across a diverse sample of client populations. The successful use of MI across cultures is generally attributed to evocation, reflection, and empathy, which are core MI skills designed to build rapport and lower discord (Balan et al., 2015). MI’s focus on evocation counters the issue of mental health counselors telling clients what to do, which may highlight cultural incongruities and come across as culturally insensitive (Balan et al.). Reflection bolsters empathy and rapport and engenders a sense of collaboration rather than dissonance. Empathy is central to the MI approach and allows for greater understanding of cultural meanings and clarification of misunderstandings (Balan et al.). Just because one knows the MI approach, however, does not mean that it is applied wholesale without modification or adaptation. Balan et al. (2015) made such adaptions in their work with Latino outpatient clients struggling with major depressive disorder. Using a cultural adaptation approach outlined by Resnikow et al. (1999), Balan et al. made “surface-structure” and “deep-structure” adaptations related to their study with depressed Latino clients. Surface-structure adaptations encompass changing interventions to better match the client population, such as conducting the interview in the client’s language. Deep-structure adaptations are clearly aligned with culturally competent counseling as outlined earlier and require the mental health counselor to understand the cultural contextual powers (e.g., social, environmental) that influence the mental health condition (Resnikow et al., 1999). Both surface and deep-seated adaptations are important within the culturally competent counseling setting, and MI can be applied with both adaptations in mind. One way to use deep-structure adaptation with MI relates to how the mental health counselor is viewed. For example, many Latino clients might see the counselor as an authority figure and defer to him or her about what decisions need to be made regarding counseling treatment. This dynamic may lead to discontinuation of services when treatment discrepancies or difficulties arise. To address this potential issue, the MI skill of eliciting client concerns and disagreements as a prelude to counseling can foster a more collaborative approach. Additional activities include handouts about common obstacles to counseling success and sharing what other clients have expressed concern about (Balan et al., 2015).

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Empirical Support MI has accumulated well over 200 clinical trials showing effectiveness with several clinical issues, most notably substance abuse. Our clinical experience and conceptualization of MI suggests it is an effective approach with clients from diverse backgrounds who have experienced societal rejection and marginalization; several scholars concur due to MI’s humanistic approach that values self-determination and mutual respect (Cordisco Tsai & Sebellos-Llena, 2020). However, empirical research to confirm these impressions remains scant. In addition, most cultural adaptation research has been with Latino and Native American clients, with use among Asian populations particularly limited (Cordisco Tsai & SebellosLlena, 2020). Earlier research into MI’s effectiveness with diverse clientele has shown the approach to be effective but not necessarily better than other approaches. For example, Ahluwalia et al. (2006) found MI was not superior to advice-oriented health education among a group of African American light smokers. Arroyo et al. (2003) found MI was no more effective than CBT among Hispanics and White non-Hispanic clients struggling with alcohol addiction. Other studies with diverse clientele have demonstrated that MI is received more favorably among research participants that treatment as usual approaches. Chan Osilla and colleagues (2012) found that a web-based MI intervention was perceived as producing less shame, embarrassment, and discomfort among Spanish speaking clients who had first time DUI offenses. Other researchers have sought to test MI’s effectiveness with specific cultural populations. Bahafzallah et al. (2020) conducted a narrative systematic review to examine the effectiveness of MI and its components in people of varying ethnicities with an emphasis on how they experience MI. Despite some challenges, the researchers concluded that adjusting MI by considering culturally relevant variables in the participant’s care enhanced effectiveness of MI across most ethnic groups. In another systematic review, Self et al. (2022) sought to analyze research studies in which investigators explored the effectiveness of culturally adapted MI (CAMI). The systematic review spanned over a 20-year period, resulting in 25 peer reviewed studies that met inclusion criteria. Of the studies that utilized randomly controlled trials, 10 out of 17 showed that the CAMI condition was superior in outcome compared to the control conditions. Adaptations in the 10 studies included changes in content (using cultural information about values and traditions), concepts (reframing treatment model to match what are important character traits within a culture), and context (considerations on stress, social supports, economic hardships, and client’s relationship to culture of origin; Bernal et al., 1995). Although not empirically generated research, Cordisco Tsai and SebellosLlena (2020) proposed several observations of what MI would look

160 Applications of MI in CMH Settings like with a Filipino population, focusing on manifestation of resistance, change talk, authority patterns, and language. For example, the concept of “resistance” in the Filipino culture is often a quieter manifestation than the more commonly described resistant behavior of actively disengaging or becoming defiant. Examples may include missing appointments, not answering phone calls, or not engaging in the treatment plan. These forms of resistance, although detrimental to treatment, ensure the expression of Filipino values maintaining harmony and social acceptance in relationships (Cordisco Tsai & Sebellos-Llena). But how does a counselor “roll with resistance” when these softer forms of resistance manifest? After all, when a client is openly resistant in a counseling session, or when discord between client and counselor is high, MI protocol suggests that we reflect, use OARS, and stress client autonomy. Cordisco and Sebellos-Llena suggested that, with Filipino clients, the counselor give space and understand that not making appointments may be a subtle way to show a mismatch between client and counselor goals. After some time, it is advised to reach out to the client and return to the engagement stage of MI, followed by emphasizing listening to clients, following OARS, and expressing empathy. Counselors can then prioritize understanding the client’s viewpoint and not moving forward until the client expresses readiness to change in words and behaviors (Cordisco & Sebellos-Llena). Using these strategies with Filipino clients, counselors can demonstrate pakikisama, which translates to “maintaining smooth interpersonal relationships” (Cordisco & Sebellos-Llena, p. 48). The strategies for using MI with Filipino clients outlined by Cordisco and Sebellos-Llena (2020) represents a useful model for how MI should be considered with clients from different cultural backgrounds. As with all multicultural counseling efforts, gaining knowledge in the client’s cultural background, as well as awareness of one’s own culture assumptions, is essential. Mental health counselors must be vigilant to avoid making interpretations based on their own worldview. For example, a mental health counselor may interpret non-attendance by a client from a different background as being uninterested in change or counseling. However, the client may be quite interested in change, but the strategy going about that change is not a fit. To preserve pakikisama or relationship harmony, the client may not show up to sessions to avoid confrontation. Allowing time to pass, reaching out and re-establishing engagement, and getting on the same page are useful strategies for culturally adapted MI with Filipino as well as diverse clients. Interestingly, some research has demonstrated that MI without adjustment for culture does not negatively impact client outcomes among minority groups (Cordisco Tsai & Sebellos-Llena, 2020). Two meta-analyses bear this finding out (Hettema et al., 2005; Lundahl et al., 2010). Lundahl et al.’s work, for example, showed non-adjusted MI to be particularly effective for clients from ethnic minority groups, except for the possibility

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of African Americans. This finding emerged when MI was compared to a treatment as usual (TAU) alternative; however, when compared to a “weak” alternative treatment, MI was correlated with positive outcomes for both Hispanic Americans and African American clients. More research is needed to confirm these findings. Overall, researchers have found MI, either adapted or in traditional form, useful with diverse populations, although more research is needed with specific cultural groups. In some cases, adding cultural activities or elements in conjunction with MI appears to boost its effectiveness. However, there is yet to be a coherent method for cultural adaptation of MI (Self et al., 2022). Based on current research, the astute mental health clinician should assess for the appropriateness of MI, or elements of MI, with specific cultural population. There is no “one size fits all” (Self et al. 2022). We now turn to a case example in which MI is adapted for use in a culturally sensitive manner. Case Example: Using Motivational Interviewing in a Culturally Sensitive Manner Our experiences with MI have shown it to be a viable approach for clients with diverse backgrounds and offers many advantages within a culturally diverse client population. It’s emphasis on autonomy, evocation, collaboration, and acceptance allows for discussions relevant to the client, including issues surrounding culture. In our work with clients using MI, we have found that cultural issues typically occur when clients come from backgrounds that emphasize a more collectivistic approach to solving problems. As with many traditional therapeutic approaches, MI places strong emphasis on individual autonomy and personal responsibility. Clients from cultural backgrounds that value the role of family and community in one’s own healing may question such a strong emphasis on individual accountability. Lack of progress in counseling must not be construed as “laziness” or “unmotivated” but rather a misunderstanding of the client’s values and culture. MI should not be applied wholesale without considerations of diversity and culture. Does this mean that to use MI with culturally diverse clients, we must abandon the integrity of the approach? Not at all. A brief example of using MI in a culturally appropriate way is illustrated in the following. In my (TFL) university work, I was fortunate to be a part of a large health disparities research grant, based on a study to test the effectiveness of MI in the prevention of diabetes among at-risk African Americans. The main targets for behavior change were improved diet and exercise/movement. Compared to a control condition, who received reading materials and information, the experimental group participated in seven MI sessions across six months. My role in this research

162 Applications of MI in CMH Settings was twofold: First, I was tasked with teaching MI to research assistants, who were students in our counseling program. Second, I was to use MI myself with research participants to help them increase motivation to improve their diet and increase exercise. As I conducted the counseling sessions, it occurred to me that the way I was using MI may not have been what participants needed. For example, I remained loyal to the principles and spirit of MI, but some participants wanted to be told what to do. With the importance of change already high, they wanted advice on healthy food choices and exercises. In my opinion, it was too early to offer advice, even though within an MI protocol giving advice is appropriate if used correctly. Thus, I avoided giving advice too early. These early experiences led me to realize that I needed to be more intentional about incorporating cultural perspectives and activities within the MI approach. For example, many of the participants had extended families and strong ties to communal living. Although not technically MI, I intentionally brought loved ones’ perspectives into our sessions, followedup with OARS, and, where appropriate, developed discrepancies between what others hope for the participant (healthier life via eating and movement) and how the participant is behaving (unhealthy eating, not exercising). Because participants had asked for advice, I found myself at liberty to give information that clients wanted, albeit in an MI-consistent manner (i.e., with permission). I respected my clients wish for advice, asked permission before I gave it, and found that participants gained more momentum in their diet and exercise than in previous sessions. The African American community values education, and psychoeducation about diet and exercise gave energy and momentum to our sessions. Being more culturally sensitive and aware in my application of MI did not dilute the approach; in fact, my use of MI in a culturally sensitive manner only strengthened rapport and helped clients find direction in taking charge of their health. This experience was confirmed by Longshore and Grills (2000), who found that MI with African American’s struggling with illegal drug addiction clients may be enhanced if cultural values are included as part of the counseling process. It is a cultural counseling lesson that I continue to teach to my graduate students today.

Summary MI’s emphasis on absolute worth, honoring client attitudes and values about change, compassion, and affirmation makes it applicable for clients and families across a range of diverse backgrounds. However, despite this consensus, carelessly applying MI the same way to all diverse clients and families is likely to backfire. For example, some cultural groups do not share MI’s emphasis on individual autonomy and change, preferring

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to focus more on the collective influence in change. In these instances, adjustments are needed. Across several empirical studies, researchers have adapted MI to the cultural groups for whom they were working, with success (e.g., see Balan et al., (2015). MI fits as a culturally sensitive approach in its ability to be flexible and understanding how cultural values play an important role in how one conceptualizes motivation and behavior change. Activities and Resources 1. The following case vignette is divided into two sections. Read the first section, stop, and answer the questions. Then, continue reading the case and again answer the questions. Anthony is a 32-year-old African American man residing in the midwestern United States. He reports being raised in a supportive family environment. Two years ago, Anthony suffered a serious fall a work, resulting in debilitating back and leg pain. His doctor prescribed opioid pain medication to help Anthony manage his pain. Although the pain has somewhat subsided, Anthony continues to use pain medication, and has recently admitted to his counselor that he sometimes takes more than his doctor authorized. He worries that he might be addicted and has experienced some of the withdrawal effects from stopping or cutting down prolonged opioid use. Anthony also feels anxious because of the common biases and stereotypes regarding African American men and drug abuse. He doesn’t see himself as “addicted,” but is afraid to share his concerns with others, including his doctor, because of these stereotypes. The counselor assigned to Anthony’s case is a male European American working in an outpatient clinic specifically geared toward mental health and addiction issues. The counselor stresses to Anthony the importance the individual effort, hard work, and self-control. He suggests to Anthony that he is indeed addicted and needs to move off the pain medication, enter physical therapy, and explore mind-body approaches to better managing his pain. It will take a lot of work, but with strong will-power, he can do it. At this point in the case, what perspective/value system is the counselor operating? Do you agree with the counselor’s assessment? How might you intervene using a more MI-consistent approach? A little more about Anthony’s background. Although Anthony was raised in a loving family, drinking was common. His father, an alcoholic, left the family when he was nine years old. His mother raised Anthony and his two sisters by herself, working one full-time and one part-time job. He has a strong relationship with his mother, who always stressed that the family stay together. In addition, the town in which he grew up did not provide much opportunity for jobs or

164 Applications of MI in CMH Settings education. He had to take care of his many siblings and, at times, missed school to do so. For Anthony, his family and community have been very important in his life. Given this new information, what can this counselor do to incorporate multicultural awareness within counseling? What key multicultural issues might you focus on in your evaluation and treatment with Anthony? From and MI perspective, how would you address Anthony’s view that he doesn’t see himself as addicted but worries he might be? 2. Association for Multicultural Counseling and Development (AMCD) website (https://multicultural-counseling-network.mn.co. AMCD is a division of the American Counseling Association. This website offers important information in how to become more active in multicultural and diversity issues within counseling. They promote numerous learning opportunities through conference presentations, journal articles, and theoretical papers. AMCD strives to improve cultural, ethnic, and racial empathy and understanding by programs to advance and sustain personal growth.

References Ahluwalia, J. S., Okuyemi, K., Nollen, N., Choi, W. S., Kaur, H., Pulvers, K., & Matthew, S. (2006). The effects of nicotine gum and counseling among African American light smokers: A 2x2 factorial design. Addiction, 101, 883–891. Arroyo, J. A., Miller, W. R., & Tonigan, J. S. (2003). The influence of Hispanic ethnicity on long-term outcome in three alcohol-treatment modalities. Journal of Studies on Alcohol, 64, 98–104. Bahafzallah, L., Hayden, A. K., Bouchal, S. R., Singh, P., & King-Shier, K. M. (2020). Motivational interviewing in ethnic populations. Journal of Immigrant Minority Health, 22, 8–16–851. Balan, I. C., Moyers, T. B., & Lewis-Fernandez, R. (2015). Motivational pharmacotherapy: Combining motivational interviewing and antidepressant therapy to improve treatment outcomes. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford. Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23, 67–82. http://dx.doi.org/10.1007/BF01447045. Chan Osilla, K., D’Amico, E. J., Diaz-Fuentes, C. M., Lara, M., & Watkins, K. E. (2012). Multicultural web-based motivational interviewing for clients with first time DUI offense. Cultural Diversity & Ethnic Minority Psychology, 18, 192–202. Chang, C. Y., Lambert, S, & Goodman-Scott, E. (2017). Chapter 3: Advocacy and social justice. In J. S. Young & C. S. Cashwell (Eds.), Clinical mental health counseling: Elements of effective practice. Sage.

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Cordisco Tsai, L., & Sebellos-Llena, I. F. (2020). Reflections on adapting motivational interviewing to the Filipino cultural context. Practice: Social Work in Action, 32, 43–57. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91–111. Lee, C. C. (2019). The cross-cultural encounter: Meeting the challenge of culturally competent counseling. In C. Lee (Ed.), Multicultural issues in counseling: New approaches to diversity (5th ed., pp. 13–23). American Counseling Association. Lewis, T. F. (2014). Substance abuse and addiction treatment: Practical application of counseling theory. Pearson. Longshore, D., & Grills, C. (2000). Motivating illegal drug use recovery: Evidence for a culturally congruent intervention. Journal of Black Psychology, 26, 288–301. Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20, 137–160. Miller, W. R., Rollnick, S., & Moyers, T. B. (1998). Motivational interviewing: Professional training videotape series. The University of New Mexico. Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W.-C., & LaFromboise, T. (2005). State of the science on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology, 1, 113–142. National Institute of Mental Health. (2021). Mental illness. Retrieved from www. nimh.nih.gov/health/statistics/mental-illness Pedersen, P. B. (1991). Multiculturalism as a generic approach to counseling. Journal of Counseling and Development, 70, 6–12. Pedersen, P. B. (1995). Culture-centered counseling skills as a preventive strategy for college health services. Journal of American College Health, 44, 20–26. Resnikow, K., Baranowski, T., Ahluwalia, J. S., & Braithwaite, R. L. (1999). Cultural sensitivity in public health: Defined and demystified. Ethnicity and Disease, 9, 10–21. Self, K. J., Borsari, B., Ladd, B. O., Nicolas, G., Gibson, C. J., Jackson, K., & Manuel, J. K. (2022). Cultural adaptations of motivational interviewing: A systematic review. Psychological Services. Advance online publication. http:// dx.doi.org/10.1037/ser0000619. Wagner, C. C., & Connors, W. (2010). Motivational interviewing network of trainers: MINT trainers list. Retrieved from www.motivationalinterview.org White-Kress, V. E., Eriksen, K. P., Dixon Rayle, A., & Ford, S. J. W. (2005). The DSM-IV-TR and culture: Considerations for counselors. Journal of Counseling & Development, 83, 97–104.

Part III

Training and Professional Development in Motivational Interviewing Part III includes Chapter 10, which looks at how clinical mental health (CMH) counselors can further develop their skills in learning motivational interviewing (MI). There are two key research-supported elements to effectively learning MI. First is understanding the philosophy and skills, and second is practicing the approach under coaching or supervision. The chapter will focus on best practices in learning MI based on guidelines from the Motivational Interviewing Network of Trainers (MINT). We place special emphasis on how to refine one’s MI skills after formal training. The chapter will be relevant to personal and organization-wide MI training, for those counselors and agencies who wish to incorporate MI as a guiding philosophy for their CMH practice.

DOI: 10.4324/9781351244596-12

10 Training and Professional Development in Motivational Interviewing

Introduction In this chapter, we provide an overview of training and professional development strategies for learning motivational interviewing (MI). We begin by exploring the core tasks associated with learning MI. We then describe the types of trainings and formal learning experiences that can help you learn and practice MI. Finally, we offer a menu of professional development strategies (deliberate practice, communities of practice, and coding and self-assessment) to maintain and enhance your MI skills following formal training. Training in Motivational Interviewing It can be helpful to begin a discussion of training in MI by reviewing a developmental sequence for MI learning proposed by Miller and Moyers (2006). This sequence for learning MI has eight stages, now known as tasks (Rosengren, 2018): (1) understanding and communicating MI Spirit, (2) intentional use of client-centered skills (i.e., open-ended questions, affirmations, reflective listening, and summaries), (3) recognizing and reinforcing change talk, (4) evoking and strengthening change talk, (5) responding to sustain talk and discord, (6) developing and refining a change plan, (7) consolidating client commitment to change, and (8)  blending MI with other counseling approaches (Miller & Moyers, 2006). Rosengren (2018) added a task related to understanding and working with the four MI processes (i.e., engaging, focusing, evoking, and planning), placing it between communicating MI spirit and use of client-centered skills. These tasks do not have to be learned in the particular order in which they were created, and some are not essential to be able to use MI (e.g., use with other modalities; Miller & Moyers, 2021; Rosengren, 2018); however, they can provide a general framework or roadmap for learning MI. Attending a two-day introductory MI training is a good way to begin developing competency in MI. Meta-analytic research has found that DOI: 10.4324/9781351244596-13

170 Training and Professional Development in MI participation in an MI training workshop yields greater gains in skills compared to self-directed study of MI materials (de Roten et al., 2013; Martino et al., 2010; Schwalbe et al., 2014). These findings indicate that reading a book or watching training videos might increase one’s knowledge of MI concepts, but actual practice is necessary to learn how to use MI skills. The format and schedule of an introductory workshop may vary depending on how it is delivered; for example, due to the COVID-19 pandemic, many of our in person two-day introductory trainings in 2020 and 2021 were rescheduled as four, three-hour online sessions scheduled over several weeks. In terms of the efficacy of virtual versus in-person trainings, researchers have found that trainings held online are equally as effective in teaching skills as in person workshops (Mullin et al., 2016). Regardless of the particular format, introductory workshops typically include a combination of didactic instruction, discussion, observation of video demonstrations, and experiential activities that allow for lots of practice (Di Bartolomeo et al., 2021). Also, introductory workshops tend to focus on the initial tasks of learning MI outlined by Miller and Moyers (2006; Madson et al., 2009). On the other hand, intermediate and advanced clinical trainings typically provide opportunities to refine core MI skills (e.g., reflective listening) and explore tasks related to managing discord, consolidating commitment, and using MI with other theoretical modalities (Rosengren, 2018). Further, advanced training also place a premium on practicing skills, even more so than introductory workshops. One way to identify MI workshops and training opportunities in your area is to search the training schedule on the website of the Motivational Interviewing Network of Trainers (MINT, 2020b). MINT is an international organization that promotes good practice in use, training, and research in MI (2020a). Members of MINT must demonstrate their ability to practice MI and participate in a train-the-trainer workshop designed to teach best practices for training in MI (2020a). As a result, workshops conducted by MINT members are more likely to reflect the latest advancements in MI practice and use empirically informed training strategies. Professional Development Findings in the MI training and professional development literature indicate that skillful MI practice requires additional inputs and followup beyond the initial training. Meta-analyses of training studies show that gains in MI skills quickly erode without post-training professional coaching or supervision (de Roten et al., 2013; Schwalbe et al., 2014). Although post-training professional development is essential to maintain skillfulness, there are a number of barriers that can prevent counselors from seeking out and receiving this support. In a study of continuing education for substance abuse counselors, only 3.8% of the participants who

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attended a two-day workshop in MI participated in post-training consultation (Doumas et al., 2019). Difficulty recording counseling sessions to use as part of the consultation and finding time to schedule the sessions were some of the reasons why workshop attendees did not participate. Other researchers have found that low motivation among MI learners was a barrier to continued skill refinement following initial training in MI (Barwick et al., 2012). Given these challenges, we present a menu of three possible strategies for professional development that clinical mental health (CMH) counselors can use to enhance their understanding of MI concepts and strengthen their MI skills. Deliberate Practice One way to refine your MI skills is through deliberate practice. Unlike mere repetition or time spent practicing a skill, deliberate practice involves targeted and persistent efforts to improve specific skills combined with reliable feedback on your performance. According to Miller et al. (2020), deliberate practice in counseling has four components: (1) personalized learning goals, (2) regular feedback concerning performance and learning, (3) involvement of an expert coach, and (4) successive refinement of skills through repetition. Evidence in the literature supports the use of deliberate practice in counseling (Miller et al., 2020); for example, Chow et al. (2015) found that the amount of time spent improving therapeutic skills predicted client outcomes. Though still in its early stages, research on the use of deliberate practice and learning MI is intriguing. Westra et al. (2021) found that therapists who participated in a deliberate practice-based workshop compared to a traditional didactic workshop on how to respond to client resistance and ambivalence demonstrated greater observer-rated MI skills and interviewee-rated empathy during a 20-minute interview with an ambivalent community member following training. Analysis of interviewee language during these post-workshop interviews by Di Bartolomeo et al. (2021) found that therapists in the deliberate practice workshop evoked fewer statements that represented interviewee resistance or opposition to the therapist. How can you use deliberate practice to improve your use of MI skills? Rousmaniere (2016) proposed five basic principles that provide a framework for establishing and maintaining a deliberate practice routine. These principles are iterative, meaning that as one successfully refines certain skills, they can continue to cycle through the principles to address other areas of professional growth. This process is similar to the PlanDo-Study-Act method of improving the quality of health care systems (see Taylor et al., 2014). According to Rousmaniere, the first principle in deliberate practice is to observe your work. Of course, your ability to observe your counseling sessions will depend on client consent to recording. We have found that clients are generally receptive to recording their

172 Training and Professional Development in MI counseling sessions once the counselor has communicated the purpose of the recordings (i.e., it is to improve service delivery) and how the recordings will be safeguarded to protect client confidentiality (e.g., when will they be destroyed). Observing your work can help you establish a baseline of your MI skills and provides grist for the mill during coaching sessions with an MI expert. Seeking an expert coach relates to Rousmaniere’s (2016) second principle, receiving expert feedback. The expert feedback can be from a coach, consultant, or clinical supervisor who is skilled in using MI. Receiving expert feedback on your use of MI may require seeking consultation or coaching from someone other than your clinical supervisor. For example, some of my former students have reached out to me (EW) years after taking my introductory course in MI asking for coaching on their MI skills. They had contacted me because no one at their agency was trained in MI and they wanted feedback on their use of MI. If no one at your site has expertise in using MI, consider using the trainer list (2020b) on the website of the Motivational Interviewing Network of Trainers (MINT) to find MINT members in your area who offer coaching and consultation services. According to Miller et al. (2020), expert coaches help learners see what they are unable to see about their clinical performance. This makes it critical for your coach to view recordings of your interactions with clients; observing your work directly can offer greater insight into your use of skills and therapeutic presence compared to what can be learned from your own reports of how you think your sessions went. This is supported by research that found that counselor self-reported ability in using MI did not predict objectively measured MI skills (Mullin et al., 2016; Wain et al., 2015). Coaches can provide encouragement, affirmation, as well as concrete instruction for refining specific skills based on viewing samples of your work. This can include feedback related to your application of the relational (i.e., MI Spirit) and technical (i.e., evoking and strengthening change talk) components of MI. Feedback given by an expert coach can be supplemented with analysis of data collected using routine outcome monitoring measures and formal coding systems that offer objective feedback on client progress and your application of MI skills and concepts (Miller & Moyers, 2021). We will discuss the use of these tools in counseling later in this chapter. When establishing a deliberate practice routine, your coach can help you with Rousmaniere’s (2016) third principle of deliberate practice: setting incremental learning goals. Goals should be small and set just beyond your baseline ability (Rousmaniere, 2016). Small well-defined goals allow for purposeful and repetitive practice of specific components of MI. For example, instead of establishing a very broad goal of “improving your use of OARS,” set a more precise goal that isolates specific MI skills, such as “improving your use of reflective listening when engaging.” Setting

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goals that are challenging, yet still within reach, is based on Vygotsky’s (1978) concept of the zone of proximal development. The zone of proximal development is the space between your current skill level and your potential as a learner. Goals set within this zone help the learner bridge the gap between their current abilities and what they cannot yet do. Your goals should be centered on skill development (e.g., improving your use of affirmations) rather than your desired outcomes, or on what you hope to accomplish through your efforts (e.g., increase client ability change talk). Continuously setting and accomplishing small incremental learning goals that gradually enhance your skillfulness increases your control over the factors that contribute to these outcomes (Miller et al., 2020). Once learning goals are established, repetitive and intentionally tailored behavioral rehearsal begins. Rousmaniere’s (2016) fourth principle of deliberate practice involves successive refinement of specific skills using videotape or role play. Suppose you want to improve your use of affirmations—a common learning goal of beginning MI counselors. You can start by watching a session with a client to identify times when the  use of an affirmation would have been appropriate. You can consider  the purpose of using the skill at each point in time (e.g., to strengthen the  therapeutic alliance, enhance client self-efficacy) and determine what specific value, attribute, strength, or effort you would have acknowledged. Importantly, you should also practice offering affirmations, writing one or more statements for each instance when this skill could have been helpful to use. Whereas it may seem strange to talk to a computer monitor, I (EW) encourage my supervisees to “speak directly to the client” when viewing recordings and write down what they said. This makes the responses generated in this rehearsal exercise more spontaneous and natural. Once completed, sharing your responses with your MI coach can help you refine your use of MI skills in future practice and in session with clients. Your learning goals should inform which clients or sessions to watch or simulate with a role play. If you want to work on your ability to roll with resistance, viewing recordings of sessions when you detected some discord makes sense. Or, you can have your MI coach role play clients that you find especially challenging. Role playing has its strengths and limitations; simulated interactions rarely resemble actual clinical encounters, yet role plays do allow for immediate feedback and provide an opportunity to try out and observe the impact of using different skills in real time. In addition to using your own perceptions and observations to select sessions for rehearsal, you can use feedback from your coach or data collected through the use of objective assessments. Depending on your specific learning goals, measures of therapeutic alliance, such as the Session Rating Scale (SRS; Miller et al., 2005) and instruments designed to assess client motivation can be used to help narrow down the specific sessions

174 Training and Professional Development in MI to watch or role play. Low scores on the Change Questionnaire (Miller & Johnson, 2008), for example, may signify that a client is a good candidate for practicing skills that can help strengthen change talk. We encourage you to build these exercises into your daily routine. Finding time for professional development can be a challenge; however, Rousmaniere (2016) suggested that beginners engage in deliberate practice in 20-minute intervals three times per week. As you become more comfortable with the routine, time spent on these exercises should increase to approximately one hour per day (Rousmaniere, 2016). The idea is that the more you rehearse outside of counseling, the more likely those skills will become ingrained and come naturally to you in session. As you watch recordings and rehearse different skills, you should monitor anything you notice about yourself. These internal reactions can provide critical information in understanding any potential blocks to using MI skills. For example, you may notice that your righting reflex creeps up and gets in the way of offering empathy and actively listening to certain clients. Finally, it is important to take some time after each deliberate practice rehearsal to reflect on the experience (Rousmaniere, 2016). This can help you refine or modify your routine and can potentially increase your self-efficacy if you notice improvements in your use of MI during your practice sessions. Rousmaniere’s (2016) fifth principle of deliberate practice helps answer the question: how do I know that my efforts are paying off? As part of your deliberate practice plan, you should regularly assess your performance using client-reported outcomes (Rousmaniere, 2016). In mental health settings, client-reported routine outcome monitoring might involve the use of a brief symptom checklist, such as the Patient Health Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002) for depression, or measure of wellbeing (e.g., Outcome Rating Scale; Miller et al., 2005). Use of idiographic approaches to outcome assessment can be advantageous because they allow for more precise assessment of client progress. For example, the Youth Top Problems Scale (Weisz et al., 2011) is a customized client self-report questionnaire administered each session to monitor the severity of the client’s greatest concerns at the start of treatment. Given the many external factors that can influence the effectiveness of counseling, counselors also should use measures that assess the active ingredients or mechanisms of change that make MI successful. This includes the technical mechanisms (i.e., increasing client pro-change language), which can be monitored using assessments of readiness to change, such as the University of Rhode Island Change Assessment Scale—Psychotherapy Version (McConnaughy et al., 1989) and Stages of Change Readiness and Treatment Eagerness Scales (Miller & Tonigan, 1996). The Change Questionnaire (Miller & Johnson, 2008) is a more recent 12-item self-report instrument that assesses client-reported

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motivation to change using items that represent different types of preparatory and mobilizing change talk. Therapeutic alliance measures, such as the Session Outcome Scale (Miller et al., 2005), can help obtain client feedback related to the relational mechanisms of MI (i.e., MI Spirit). One would expect that improved counselor ability to convey acceptance and partnership in session would result in higher levels of perceived therapeutic alliance by the client. Data should be aggregated and analyzed on a regular basis to look for patterns in client reported outcomes based on your deliberate practice routine. If ratings on specific client outcome measures begin to trend upward, this may suggest that it is time to establish new learning goals that better reflect your current zone of proximal development. Before moving onto your next goal, be sure to watch the sessions that show your success and take note of how your use of MI has changed. Also notice how the client responds to your newly refined skills (e.g., ending a double-sided reflection with change talk results in the client responding with more pro-change language). This can bolster your self-confidence and further solidify the skills developed through rehearsal by increasing your awareness of the immediate benefits of your new skills. Flat-lined or falling scores should be viewed productively (Miller et al., 2020; Rousmaniere, 2016) and may suggest that you need to step-up or adjust your deliberate practice routine. Consultation with a coach can be especially helpful when this happens. A coach can watch your sessions with clients who are not improving to increase your awareness of your in-session behaviors and help identify areas in your deliberate practice routine that need to be modified. By watching your work and receiving feedback on your successful and less successful client interactions, you can continue to fine tune your skills and improve your performance. As you can see, the principles of deliberate practice are cyclical because the fifth principle flows directly into the previous four principles. If you are successful, you start the cycle again with newly defined goals; if you are not successful yet, you can work with your coach to adjust your plan moving forward. Communities of Practice Another strategy for improving MI skillfulness is to organize or participate in a community of practice (Miller & Rollnick, 2013; Osborn et al., 2020). Communities of practice are groups of counselors who share an interest in working together to improve their MI skills. Though it is not necessary for an expert in MI to be a regular member or facilitator of these groups, it can be helpful to invite a coach to attend meetings periodically to offer feedback on group processes as well as each member’s use of skills (Miller & Moyers, 2021). Community of practice meetings typically involve some combination of focused discussion on MI topics

176 Training and Professional Development in MI and collaborative practice of MI skills. This is done by viewing or listening to excerpts of recorded client sessions or through live “real-play” practice by members. Real plays are when the “client” or speaker discusses something real rather than made-up like in a role play. A common topic for real play practice of MI is to discuss a behavior that the speaker is ambivalent about changing. According to Miller and Rollnick (2013), real plays are preferred over role plays because they better mimic counseling and can lead to more genuine and realistic exchanges. We do caution that the content of real play sessions can become fairly deep and sometimes enters into unexpected territory. This probably comes as no surprise given the emphasis in MI on exploring values and use of reflective listening skills. As a result, group members should select topics that are meaningful yet are not too personal to avoid potential boundary issues or veering into areas of the speaker’s life that go beyond the scope of a brief practice exercise. Both Miller and Rollnick (2013) and Frey and Hall (2021) provide practical suggestions for structuring communities of practice. Members should have shared MI learning goals and establish a structure and regular schedule for the group meetings. This includes who will chair or facilitate each session. Frey and Hall suggest that learning communities meet at least once every two weeks and spend most of the meeting time on practice. Real-play practice or clips of recorded counseling sessions should not last more than 10 minutes, and group members should be assigned specific coding tasks while observing (Miller & Rollnick, 2013). Some group members can observe the client, recording examples of change talk and sustain talk, and others can concentrate on the counselor, monitoring use of MI-consistent and MI-inconsistent behaviors. One way to demonstrate how differential reinforcement of client language can influence the direction of a conversation is to have an observer monitor the trajectory of change talk and sustain talk during the interaction. By selectively responding to client change talk, one would expect to see an increase in change talk and a corresponding decrease in sustain talk during the course of the interaction. Depending on the level of expertise of the group members, a coder can monitor and record examples of preparatory and mobilizing change talk to identify possible shifts in the client’s readiness to change. Communities of practice can use the Motivational Interviewing Treatment Integrity Coding Manual (MITI; Moyers et al., 2014) as a framework for assigning group member roles in observing the counselor. Specifically, observers can take one of the three sections of the MITI: global relational components (i.e., observe partnership and empathy), global technical components (i.e., observe efforts to cultivate change talk and soften sustain talk), and behavioral counts (record examples of specific MI behaviors). Learning community members should use a strengths-based approach consistent with the spirit of MI when debriefing practice sessions. Debriefing

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should begin with some discussion of how the experience went for the person practicing MI. For real-play exchanges, the speaker (i.e., the client) should speak next about the interaction (Miller & Rollnick, 2013). Feedback from the group should be limited, as we have found that providing a lot of feedback can be overwhelming to the receiver. Instead of having every group member share what they observed, only three specific observations or suggestions should be offered by the group. Feedback given by group members should be tailored to the learning goals of the person practicing MI and most of the feedback should be positive, highlighting the practitioner’s strengths (e.g., two examples of something that the counselor did well, followed by one example of a behavior that hindered the session or could be improved in the future). To support autonomy, peer observers should ask permission before offering feedback. If the observers used a formal coding system to rate and record examples of MI skills used by the counselor, these forms can be distributed afterwards to be reviewed outside of the meeting for more in-depth analysis of the demonstration. Strategies and principles from the literature on peer supervision of mental health counselors and other helping professionals can help enhance skill development and keep the format of these learning communities fresh. Members should agree to (and revisit on a regular basis) procedures, responsibilities, and norms for group processes that create a safe and supportive environment conducive to open discussion and honest feedback (Borders, 2012). In addition to coding client or counselor responses, group members can observe and provide feedback in other ways. Some group members can think metaphorically about the demonstration and share a metaphor when providing feedback about what they observed. According to Borders (1991), this approach can be especially helpful when there is a request for feedback from the counselor related to interpersonal dynamics (e.g., discord). Another strategy recommended by Borders for peer supervision that can potentially invigorate and deepen feedback exchange is to have observers provide first-person feedback from the perspective of the client or counselor using I language. This process commentary can increase counselor self-awareness and insight into how the use of MI skills impacted the client. Coding and Self-Assessment A third way of developing expertise in MI is through coding and selfassessment. Fortunately, there are many coding tools available to assess competency and fidelity in MI. Each of these instruments has its strengths and limitations. Gill et al. (2020) found that some MI competency tools had significant administrative burdens and training needs, thus limiting their utility in training contexts. These authors also found that most

178 Training and Professional Development in MI instruments lacked psychometric rigor, such as reliability and validity. In a content analysis of MI fidelity tools, Lundahl et al. (2019) found that most adherence measures focused on counselor behaviors rather than client responses. Observing only the counselor paints an incomplete picture of MI effectiveness as it fails to capture the impact of counselor’s use of MI skills on client motivation or the direction of the session. For example, a counselor might use many complex reflections to draw out change talk, but it is difficult to determine if those skills actually evoked and strengthened client change talk without examining the client’s responses during the exchange. Lundahl and colleagues also found that several essential MI components (e.g., focusing, planning, and providing information) were underemphasized or omitted in nearly all the 28 instruments they had examined. The MITI (Moyers et al., 2014), the most popular used MI fidelity tool (Gill et al., 2020), is a 14-item rating system of counselor behaviors with coding of 10 specific behavioral and four global ratings that measure the technical and relational components of MI. Strengths of the MITI include its focus on identifying MI consistent and inconsistent counselor behaviors and inclusion of suggested thresholds for determining basic competence and proficiency in MI based on behavioral counts and global ratings of the counselor. According to Gill et al. (2020), the MITI instrument possesses sound psychometric qualities for measuring MI skills. However, the MITI has several limitations; specifically, the MITI is not meant to assess counselor use of engaging or focusing skills (though some of the global scales and behavior counts can yield helpful information on these dimensions of MI) and it is challenging to use the MITI to code interactions that involve a change target that is not a behavior (Moyers et al., 2014). Another limitation of the MITI is that it does not include a coding system for client responses. Counselors who are interested in coding both counselor and client responses can use the Motivational Interviewing Skills Code (MISC; Houck, Moyers, Miller, Glynn, & Hallgren, 2010). Like the MITI, the MISC has well established psychometric properties (Gill et al., 2020); however, it is more complex and time intensive (e.g., it requires three passes or viewings of a recorded session). The MISC 2.5 has a coding system for assessing client language that captures client sustain talk as well as different types of preparatory and mobilizing change talk. Summary scores provided from the MISC include percentages of the counselor’s use of complex reflections, open questions, and MI-consistent responses as well as the ratio of reflections to questions (Houck et al., 2010). Also reported is the overall percentage of client change talk (Houck et al., 2010), which can provide valuable insight into the counselor’s success in effectively drawing out pro-change language from the client and guiding the conversation in the direction of change. Use of the MITI or MISC requires formal training and regular support to ensure valid and reliable coding (Gill et al., 2020). If you do not have

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the resources or time to learn to use a formal MI fidelity instrument, you can still engage in professional development by reviewing recordings of your client counseling sessions. This can include counting your use of open-ended questions, affirmations, reflections, and summaries. The MITI’s thresholds for MI proficiency (e.g., two-to-one ratio of reflections to questions, 50% of reflections are complex; Moyers et al., 2014) can help you evaluate your MI skills and establish learning goals. Monitoring your recordings for examples of partnership, conveying empathy, and acceptance can offer insight into the quality of the therapeutic relationship as well as your ability to embody MI Spirit. The MITI global ratings for the relational components of MI (Moyers et al., 2014) can serve as helpful a framework for self-assessment of this aspect of using MI. In addition to counting your behaviors and monitoring MI spirit, it can be beneficial to use the four processes of MI (i.e., engaging, focusing, evoking, and planning) to reflect on the timeliness or strategic use of your MI behaviors in session. For example, perhaps a reflection that was meant to strengthen change talk resulted in a discord response from the client because more engaging was needed. The four processes also can help determine what went wrong in sessions where your use of MI was unsuccessful (e.g., we have found that it is not uncommon for early MI learners to bypass the processes of engaging and focusing and jump right into evoking change talk). Therefore, noting the specific MI processes in your sessions can be a useful part of your self-assessment process. This can be done by stopping the recording every five to eight minutes to consider what processes had played out in the exchange and determine if any process-related tasks had not been addressed. Although self-assessment and coding can be done alone, we encourage you to work with a colleague who shares an interest in learning MI. Having someone available to compare notes with and discuss your coding can sharpen your skills as coder and provide you with someone who can hold you accountable to making time in your schedule to watch recordings. Once you have found a MI learning partner, code a session together. This can be of an actual clinical encounter or a MI skills demonstration available for purchase (e.g., Miller et al., 2013). Coding a session together can help clarify aspects of the coding process and set expectations for how to code sessions moving forward (e.g., will you code the counselor only?); this is especially helpful when you are not using a formal coding system. Coding 20-minute excerpts of each other’s client counseling sessions and meeting regularly to compare coding notes and exchange feedback is a great way to maintain and strengthen your skills following formal training in MI.

Summary Dissemination of MI within a CMHC setting can begin with an agencywide introductory MI workshop; however, staff training should not end

180 Training and Professional Development in MI there. To help counselors consolidate new knowledge and skills, on-going training and consultation is necessary. Advanced MI workshops or briefer follow-up “booster” training sessions can be offered for counselors to explore more complex aspects of learning MI, such as MI integration with other modalities. Organizing communities of practice for counselors to regularly practice and receive feedback on their MI skillfulness provides a venue for collaborative skill development and keeps the conversation alive on how to integrate MI into routine practice. Other strategies, offering expert coaching and giving feedback based on the use of formal coding systems, also can increase counselor MI competencies and keep MI at the forefront of agency activities. In addition to training frontline staff, it is important for clinical supervisors and senior administrators to receive training in MI. It is beneficial for supervisors to learn MI so they can model these skills and provide accurate MI-informed feedback to their supervisees in clinical supervision. It is essential that senior administration support implementation efforts because of the time and resources that are needed to train staff in MI. Administrators can provide support and financial incentives for counselors and supervisors to engage in deliberate practice during the workday and attend on-going professional development opportunities. Using this comprehensive approach, MI can be successfully implemented throughout an organization.

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182 Training and Professional Development in MI Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers’ motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors, 10(2), 81–89. https://doi.org/10.1037/0893164X.10.2.81 Motivational Interviewing Network of Trainers. (2020a). Welcome to the motivational interviewing network of trainers. Motivational Interviewing Network of Trainers. Retrieved from https://motivationalinterviewing.org/about_mint Motivational Interviewing Network of Trainers. (2020b). Trainer list. Motivational Interviewing Network of Trainers. Retrieved from https://motivationalinter viewing.org/trainer-listing Moyers, T. B., Manuel, J. K., & Ernst, D. (2014). Motivational interviewing treatment integrity coding manual 4.1. Unpublished manual. Mullin, D. J., Saver, B., Savageau, J. A., Forsberg, L., & Forsberg, L. (2016). Evaluation of online and in-person motivational interviewing training for healthcare providers. Families, Systems, & Health, 34(4), 357–366. https://doi. org/10.1037/fsh0000214 Osborn, C. J., Giegerich, V., Tolbert, Y. R., Marder, S., & Emanuelson, G. (2020). A collaborative approach to learning Motivational Interviewing (MI): One MI learning community and its “MI learning day”. Journal of Counselor Preparation & Supervision, 13(2), 22–49. https://doi.org/10.7729/42.1379 Rosengren, D. B. (2018). Building motivational interviewing skills: A practitioner workbook (2nd ed.). The Guilford Press. Rousmaniere, T. (2016). Deliberate practice for psychotherapists: A guide to improving clinical effectiveness. Routledge. https://doi.org/10.4324/9781315472256 Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). Sustaining motivational interviewing: A meta-analysis of training studies. Addiction, 109(8), 1287–1294. https://doi.org/10.1111/add.12558 Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290–298. https://doi.org/10.1136/bmjqs-2013-001862 Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Harvard University Press. Wain, R. M., Kutner, B. A., Smith, J. L., Carpenter, K. M., Hu, M. C., Amrhein, P. C., & Nunes, E. V. (2015). Self-report after randomly assigned supervision does not predict ability to practice motivational interviewing. Journal of Substance Abuse Treatment, 57, 96–101. https://doi.org/10.1016/j.jsat.2015.04.006 Weisz, J. R., Chorpita, B. F., Frye, A., Ng, M. Y., Lau, N., Bearman, S. K., Ugueto, A. M., Langer, D. A., Hoagwood, K. E., & The Research Network on Youth Mental Health. (2011). Youth top problems: Using idiographic, consumerguided assessment to identify treatment needs and to track change during psychotherapy. Journal of Consulting and Clinical Psychology, 79(3), 369–380. https://doi.org/10.1037/a0023307 Westra, H. A., Norouzian, N., Poulin, L., Coyne, A., Constantino, M. J., Hara, K., Olson, D., & Antony, M. M. (2021). Testing a deliberate practice workshop for developing appropriate responsivity to resistance markers. Psychotherapy, 58(2), 175–185. https://doi.org/10.1037/pst0000311

Index

Note: Page numbers in italics indicate a figure and page numbers in bold indicate a table on the corresponding page. ability language 43 absolute worth 8 acceptance 7–9 Acceptance and Commitment Therapy (ACT) 82 accurate empathy 8 achievement 143–144 action, moving to 107 Activation change talk 43–44, 64 active listening 13 affirmation: acceptance and 9; change talk and 48, 63; examples 20–21, 21; in OARS+I 20–21, 21; selfefficacy and, bolstering 63; spirit of MI and 9, 20 agoraphobia 82 agreement with a twist 31–32 Alcohol Use Inventory (AUI) 117 altruism 99 ambivalence: achievement and 143–144; case study 49–52; change talk and 42–44, 42; inertia associated with, behavioral 37–38; overview 36, 52; reasons for 36–38; resolving 6, 38, 40–44, 42; righting reflex and 38–40; signs of 37; working with 78 amplified reflection 28–29 Amrhein, P. C. 43 anorexia nervosa 84 anxiety disorders 82–84, 89 Apodaca, T. R. 44 applications of MI 75, 77, 91–92 argumentation, avoiding 11 Arkowitz, H. 37–38, 48 Arroyo, J. A. 159 Assertive Community Treatment 132

assessment: client change, stages of 124; clinical mental health and 15; discrepancies and 46; mental status 118; motivation 124–128, 126, 173–174; self 177–179; trap 58; see also evaluation; specific instrument Association for Counselor Education and Supervision (ACES) 133–134 atmosphere of acceptance 7–8 autonomy 8–9, 39–40 Aviram, A. 83–84 Bahafzallah, L. 159 Balan, I. C. 88, 158 Beck’s Depression Inventory (BDI) 116 Bem, D. J. 40 Bernard, J. M. 132, 134, 137–138 binge eating disorder 84 blaming trap 34, 59 Borders, L. D. 137, 177 Borsari, B. 44 Brown, L. L. 137 bulimia nervosa 84 Caccavale, L. J. 39–40 CAGE assessment 116–117 cards with personal values on them, sorting 46 case studies: ambivalence 49–52; change talk 49–52; engagement 66–67; evoking 69–70; focus 67–69; group counseling 110–112; mental health problem 89–91; multicultural counseling 161–162; planning 70–72; process of MI 66–72; supervision 148–151

184

Index

Cassin, S. E. 85 catalytic interventions 135–136 catharsis 101 CATS (Commitment, Activation, and Taking Steps) 43–44, 49, 128 Centers for Disease Control and Prevention 47 change see client change Change Assessment ScalePsychotherapy Version 174 change plan 43 Change Questionnaire 174–175 change talk: Activation 43–44, 64; affirmation and 48, 63; ambivalence and 42–44, 42; case study 49–52; client change and 36, 41; Commitment 43–44, 49, 64; defining 4; Elaboration and 48–49; elements needed for 42; eliciting 44–47, 78; examples 42, 42; identifying 44; language of 42–44, 42; MI and 4, 6; mobilizing 43–44; motivation assessment and 127; outcomes related to, exploring extreme 45; preparatory 43; Reflection and 48–49, 63; responding to 47–49; Summarize 49; Taking Steps 43–44 Chang, H. S. 109 Chan Osilla, K. 159 chat trap 59 Chow, D. L. 171 Choy-Brown, M. 132 chunking information 60, 133 Clarke, P. B. 133 client change: change talk and 36, 41; commitment and 49, 146; confidence in 63, 104, 125–127, 126; counselor arguing for 39–40; importance of, perceived 63, 125–127, 126; MI on, hypotheses and 36; motivation for 5, 37, 49; planning for 107; readiness and 127; stages of, assessing 124; see also change talk clients’ thoughts, eliciting 78 clinical evaluation see evaluation clinical interview 117–118, 120 clinical mental health (CMH): applications of MI to 75, 77, 91–92; assessment and 15; communication styles in 12–13; counseling 13–15; developmental viewpoint of 14; evaluation and 115; inpatient care settings 78–80;

mental health problems and 14; MI and 13–15; outpatient care settings 80; principles, foundational 14; roles of counselors and 14; settings 13, 77, 91–92; see also mental health problems clinical screening 116–117, 116 clinical supervision see supervision coding 177–179 cognitive-behavioral supervision 139–140 cognitive behavioral therapy (CBT) 81, 83–84, 87 collaboration 7, 15, 62, 157 collecting summary 24–25 coming alongside 32–33 Commitment change talk 43–44, 49, 64, 146 communication styles 12–13, 118 communities of practice 175–177 compassion 9–10 complaints, hearing 103 complex reflection 22, 48–49 conceptual interventions 135 confidence in making change 63, 104, 125–127, 126 confrontation-denial 33 confrontive interventions 135 contemplation 10 Cordisco Tsai, L. 157, 159–160 Council for Accreditation for Counseling and Related Educational programs (CACREP) 96 counselors, motivating through supervision 142–148 countertransference 136–137, 140 Culbreth, J. 87 cultural adaptation 157 culturally adapted MI (CAMI) 159 culturally competent counseling 155 culture-centered counseling 155 Cummings, J. A. 139 D’Amico, E. J. 107–108 DARN (Desire, Ability, Reasons, and Need) 43–44, 49, 128 defensiveness, accepting 106 deliberate practice routine 171–175 depression 37–38, 80–82, 116 desire language 43 diagnosis 116, 119–120 Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5) 47, 77, 81, 82, 84–85, 119 Di Bartolomeo, A. A. 171

Index DiClemente, C. 10 directing communication style 12–13 discord: lowering level of 5–6; managing 26, 28–33; rolling with 11; term of 16n1, 26; traps 33–34; understanding 124–125 discrepancies, developing/working with 11–12, 46, 77–78 Discrimination Model 133, 137–138 disengagement traps 58–59 diversity of counseling clientele 154–155, 159 double-sided reflection 29 Dunn, E. C. 85 EARS (Elaboration, Affirm, Reflect, and Summarize) 48–49 eating disorders 84–87 Elaboration and change talk 48–49 elicit-provide-elicit (E-P-E) 121–122 empathy 8, 11 engagement: case study 66–67; group counseling and 104; in process of MI 15, 56–60; supervision and 143–144; traps 58–59 Engle, D. E. 37–38 environment, creating welcoming 59 evaluation: assessment and 116, 117–119; assessment feedback and 120–124; clinical mental health and 115; components of 116–120, 116; diagnosis and 116, 119–120; elicit-provide-elicit (E-P-E) strategy 121–122; FRAMES model 122–124; function of 115–116; importance of 115; MI and 120; overview 115, 128–129; screening and 116–117, 116; stages of change and 124–128, 126; see also assessment evoking: case study 69–70; in process of MI 57, 63–64; spirit of MI and 7; supervision and 145–147 existential factors 101–102 expertise 7 expert trap 34, 58 extremes, querying 45 extrinsic motivation 5 facilitative interventions 135 feedback, normative 46–47 Festinger, Leon 11–12 focus: case study 67–69; on future 106; on positives 103; premature focus trap 33, 58–59; in process of

185

MI 57, 60–63; shifting 29–30, 106; supervision and 144–145 following communication style 13 Foote, J. 95 forming stage of group counseling 97 foundations of MI 1; see also principles of MI; spirit of MI FRAMES model 122–124 Frey, J. 176 Fuenfhausen, K. K. 14 Geller, J. 85 generalized anxiety disorder (GAD) 82–84, 89–91 Gill, I. 177–178 Giordano, A. L. 133 Goal Attainment Scale (GAS) 65 goals of MI 5–6, 172–173 Goodyear, R. K. 132, 134 group cognitive behavioral therapy (GCBT) 108–109 group cohesion 101 group counseling: action and, moving to 107; case study 110–112; complaints, hearing 103; contraindications 109–110; effectiveness of 95; empirical support for 107–109; engagement and 104; individual versus group MI 102; inpatient care settings and 96; leading MI groups 102–107; MI and 102–107; outpatient care settings and 96–97; overview 95–96, 112; perspectives, exploring/ broadening 105–106; positives and, focusing on 103; self-efficacy and, supporting 103–104; stages of 97–98; therapeutic factors and 98; see also therapeutic factors guiding communication style 13 Hall, A. 176 Hayes, D. G. 115 heartset 18 hope, instillation of 98 hospital inpatient settings 79 Houck, J. M. 178 imitative behavior 100 importance of change, client’s perception of 63, 125–127, 126 information: chunking 60, 133; exchange 25–26; imparting 60, 99, 133 Ingersoll, K. S. 41, 102, 105–106

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Index

inpatient care settings 78–80, 96, 118 Integrated Development Model (IDM) 133–137 intensive outpatient programs (IOP) 80 Interian, A. 89 interns, motivating through supervision 142–148 interpersonal learning 100 intrinsic motivation 5 Jensen, M. A. 97–98 Kaplan, D. A. 139 key questions at end of summaries 25 Knight, K. M. 108 labeling trap 33–34, 59 labels 30 LaBrie, J. W. 108 Lanning, W. 137 Lee, C. C. 156 Leszcz, M. 98–101 Lewis, T. F. 65, 87 Lincourt, P. 108 linking summary 25 looking back/ahead 45–46 Lundahl, B. W. 160–161, 178 Macdonald, P. 86 Magill, M. 41, 47 Marcus, M. 83 Marshall, C. 140–141 McNeill, B. 134–136 medication compliance issues 87–89 memory of event 37 mental health problems: anxiety disorders 82–84, 89; case study 89–91; clinical mental health counselors and 14; depression 37–38, 80–82, 116; eating disorders 84–87; medication compliance issues and 87–89 mental status, assessing 118 Meyer, E. 108 Miller, William R. 4–9, 19, 30, 33, 36, 38–39, 42–43, 48, 56, 58–59, 64, 77, 103–104, 127, 169, 171–172, 176 Millon Clinical Multiaxial Inventory-IV (MCMI-IV) 118–119 mindset 18 Minnesota Multiphasic Personality Inventory-3 (MMPI-3) 118–119 mobilizing change talk 43–44

motivation: assessment 124–128, 126, 173–174; to change 5, 37, 49; confidence and 104; of counselors, through supervision 142–148; extrinsic 5; of interns, through supervision 142–148; intrinsic 5; lack of 3; memory of event and 37; Session Rating Scale and 173 motivational enhancement therapy (MET) 83, 92n1 motivational interviewing (MI): in anxiety treatment 82–84; applications to clinical mental health 75, 77, 91–92; change talk and 4, 6; on client change, hypotheses and 36; clinical mental health and 13–15; communication styles and 12–13, 118; culturally adapted 159; defining 3–5; in depression treatment 81–82; discrepancies and, working with 12; in eating disorder treatment 85–87; evaluation and 120; as evidencebased method of communicating/ counseling 3–4; evolution of 3–4; foundations of 1; goals of 5–6, 172–173; group counseling and 102–107; in inpatient care settings 96; learning, developmental sequence for 169; medication compliance issues and 87–89; multicultural counseling and 157–162; overview 1, 3, 15–16; philosophy of 10–11, 18; potential of 3; principles of 11–13; resistance and, working with 11; righting reflex and, resisting 40; stages/ tasks 169; as style of counseling 4; supervision versus counseling and 140–142; see also process of MI; spirit of MI; technical skills of MI Motivational Interviewing Network of Trainers (MINT) 157, 170, 172 Motivational Interviewing Skills Code (MISC) 178 Motivational Interviewing Treatment Integrity Coding Manual 176, 178–179 Motivational Interviewing Treatment Integrity Scale 127–128 motivational pharmacotherapy (MPT) 88 Moyers, T. B. 169 Muir, H. J. 83–84

Index multicultural counseling: case study 161–162; collaboration and 157; considerations in 156, 156; culturally competent counseling and 155; culture-centered counseling and 155; diversity of clientele and 154–155, 159; as fourth force in counseling 155–157; MI and 157–162; movement toward 155–157; OARS+I and 160; overview 154, 162–163; spirit of MI and 157 Naar, S. 37 National Institute of Mental Health 154 needs language 43 Newman, C. F. 139 Nielsen, A. S. 140–141 normative feedback 46–47 norming stage of group counseling 97 OARS+I (open questions, affirmations, reflections, summary, and information exchange): affirmations 20–21, 21; defining 18; information exchange and 25–26; in inpatient care setting 79; multicultural counseling and 160; open-ended questions 19–20; in outpatient care settings 80; overview 18–19; reflection 21–24; summaries 24–25; supervision and 145 obsessive-compulsive disorder (OCD) 82, 108–109 open-ended questions 19–20, 44–45, 59 Outcome Questionnaire 146 Outcome Rating Scale 146 outpatient care settings 80, 96–97 panic disorder 82 Patient Health Questionnaire-9 (PHQ9) 174 Perez, P. J. 79 performing stage of group counseling 97–98 personal choice/control, emphasizing 30–31 personalization 137 personal values 46 perspectives, exploring/broadening 105–106 Peters, L. 84 pharmacotherapy 81

187

philosophy of MI 10–11, 18 phobias 82 pica 84 Plan-Do-Study-Act method 171 planning: case study 70–72; for client change 107; in process of MI 57, 64–65, 66; supervision and 147–148 practice routine, deliberate 171–175 precontemplative clients 10 premature focus trap 33, 58–59 preparatory change talk 43 prescriptive interventions 135 principles of MI 11–13 problem-dominated stories 9 process of MI: case study 66–72; engagement 15, 56–60; evoking 57, 63–64; focus 57, 60–63; overview 56–58, 72; planning 57, 64–65, 66; in practice 56–58 Prochaska, J. 10 professional development in MI: coding and 177–179; communities of practice 175–177; COVID-19 and 170; deliberate practice routine and 171–175; literature 170–171; overview 167, 169, 179–180; selfassessment and 177–179; zone of proximal development and 173 psychiatric care, standard 88–89 question and answer trap 23, 34 readiness in motivation assessment 127 reasons language 43 recapitulation of primary family group, corrective 99–100 reflection: amplified 28–29; change talk and 48–49, 63; complex 22, 48–49; on desire, needs, plans of self 103; double sided 29; in OARS+I 21–24; simple 22 reflective listening 8, 20–21, 59, 62–63, 141, 143, 176 reflective statements 146 reframing 31 Reichenberg, L. W. 83 relational hypothesis of MI on client change 36 resistance: common occurrence of in clients 3; Freudian Psychoanalysis and 27; lowering level of 5–6; managing 28–33; MI in working

188

Index

with 11; reconsidered 26–28; rolling with 11; term of 16n1; understanding 27, 124–125 Resnikow, K. 158 Revised Cognitive Therapy Scale (CTS-R) 148–149 righting reflex 38–40 Rogers, Carl 7 Rollnick, S. 4–9, 19, 30, 33, 36, 38, 42–43, 56, 58–59, 64, 77, 79, 103–104, 127, 176 Rose, G. S. 36 Rosenblum, A. 108 Rosengren, D. B. 20, 42, 59, 64–65, 169 Rose, S. D. 109 Rousmaniere, T. 171–174 rumination disorder 84

supervision: case study 148–151; cognitive-behavioral 139–140; counselors and, motivating through 142–148; countertransference and 137; Discrimination Model and 133, 137–138; engagement and 143–144; evoking and 145–147; focus and 144–145; Integrated Developmental Model and 133–137; interns and, motivating through 142–148; interventions 135–136; MI and 133–134; MI counseling versus MI 140–142; OARS+I and 145; overview 132–133, 151–152; personalization and 137; planning and 147–148; spirit of MI and 136 sustain talk 26–27, 36, 41, 44, 63–64

Safren, S. A. 37 Santa Ana, E. J. 108 scaling questions 45 screening 116–117, 116 Sebellos-Llena, I. F. 157, 159–160 self-assessment 177–179 Self-Determination Theory 39–40 self-efficacy 12, 43, 63, 103–104, 133–134 self-harming behaviors 37 Self, K. J. 159 Self-Perception Theory 40 Seligman, L. 83 semi-structured clinical interview 117 Session Outcome Scale 175 Session Rating Scale (SRS) 173–174 shifting focus 29–30, 106 simple reflection 22 social anxiety disorder (SAD) 84 socializing techniques 100 spirit of MI: acceptance 7–9; affirmation and 9, 20; clinical interview and 118, 120; collaboration 7; compassion 9–10; evoking 7; as foundation of MI 18; multicultural counseling and 157; overview 6–7; supervision and 136 Stanhope, V. 132 status quo 7, 26, 33, 36, 38, 41–45, 145–146; see also ambivalence Stoltenberg, C. D. 134–136 storming stage of group counseling 97 substance abuse 159 summaries 24–25, 49 Summarize change talk 49

Taking Steps change talk 43–44 technical hypothesis of MI on client change 36 technical skills of MI: OARS+I 18–26; overview 18, 34–35; resistance reconsidered and 26–28; sustain talk and 26–27; see also discord; OARS+I Terlizzi, E. P. 87 therapeutic factors: altruism 99; catharsis 101; existential factors 101–102; group cohesion 101; group counseling and 98; hope, instillation of 98; imitative behavior 100; information, imparting 99; interpersonal learning 100; overview 98; recapitulation of primary family group, corrective 99–100; socializing techniques 100; universality 98–99 thought mapping 108 training in MI 169–170; see also professional development in MI transition summary 25 transtheoretical model (TTM) 10, 124–128 treatment as usual (TAU) 161 Tuckman, B. W. 97–98 universality therapeutic factor 98–99 Vygotsky, L. S. 173 Wagner, C. C. 41, 102, 105–106 Westra, H. A. 37, 39, 83–84, 171

Index Yalom, I. D. 8, 95, 98–101 Young, T. L. 109 Youth Top Problems Scale 174

189

Zablotsky, B. 87 zone of proximal development 173 Zuckoff, A. 37, 58–59