[Episode 84] Today's episode of the Social Work Podcast is about Motivational Interviewing, Third Edition. In today's episode I speak with Mary Velasquez, Ph.D., Centennial Professor in Leadership for Community, Professional and Corporate Excellence and Director of the Health Behavior Research and Training Institute at the University of Texas at Austin. Dr. Velasquez is a trainer for the Motivational Interviewing Network of Trainers and has been involved in research that informed the changes to Motivational Interviewing, Third Edition. In today's interview Mary talks about how she became involved with Motivational Interviewing, what has changed and stayed the same in the revised version of Motivational Interviewing, DARN CATS, the four change processes, and how people can experience Motivational Interviewing in less than 15 minutes.
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Bio(from UT-Austin School of Social Work faculty page)
Dr. Mary Marden Velasquez is the Centennial Professor in Leadership for Community, Professional and Corporate Excellence and Director of the Health Behavior Research and Training Institute at the University of Texas at Austin. Dr. Velasquez holds a master’s degree in clinical psychology and a Ph.D. in behavioral sciences from the University of Texas Health Science Center-School of Public Health. Her program of research focuses on the development and implementation of interventions using the Transtheoretical Model and Motivational Interviewing. With over 20 years of support from the National Institutes of Health and the Centers for Disease Control and Prevention, Dr. Velasquez has developed and studied behavioral interventions in the areas of integrated primary care, screening and brief interventions, fetal alcohol spectrum disorder, alcohol and other drug abuse, prenatal health, HIV prevention, and smoking cessation. A recent emphasis has been on teaching graduate students and health professionals to use brief motivational interventions in medical settings. She is the author of books, journal articles and book chapters on using brief interventions to facilitate treatment adherence and promote behavior change for a variety of health problems. Dr. Velasquez is an internationally recognized trainer in both Motivational Interviewing and the Transtheoretical Model, and is a founding member of the Steering Committee for the International Motivational Interviewing Network of Trainers.
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Jonathan Singer: Hey there podcast listeners. Do I have a treat for you today! Mary Velasquez is here to talk with us about what has changed and what has stayed the same in Motivational Interviewing, Third Edition. Dr. Velasquez is an educator, researcher, clinician, trainer-of-trainers, and the Centennial Professor in Leadership for Community, Professional and Corporate Excellence and Director of the Health Behavior Research and Training Institute at the University of Texas at Austin. Oh yeah. That’s a lot of titles. But the coolest thing about Mary? Nah, you’ll have to listen to the podcast for that one. Oh man, that’s so wrong to leave you hanging like that. I’ll just say that we start our conversation with a story that blew my mind.
After that we start talking about changes to MI3. Mary points out that one of the biggest changes is that Miller & Rollnick have moved away from thinking about change as happening in the 5 discrete stages described in Prochaska & DiClemente’s Stages of Change Model. In MI3, change is conceptualized as occurring in four overlapping processes: Engaging, Focusing, Evoking, and Planning. These four processes are so central to the way that Miller & Rollnick think about Motivational Interviewing that they’ve organized the book around them.
Now, long-time users of Motivational Interviewing know that MI loves acroynyms. The most well-known is the acronym OARS, which stands for Open-ended questions, Affirming, Reflective listening, and Summarizing. The OARS are four of five core skills, and the ones most closely aligned with the humanistic, person-centered side of Motivational Interviewing. The OARS are great skills to use if you want to follow your client. But, as Mary points out, Motivational Interviewing takes the stance of guiding clients, which is more directive than the following stance of person-centered therapy, but not as directive as other treatments. The 5th core skill, “informing and advising” is consistent with the stance of guiding, which she talks about when she describes the “eliciting-providing-eliciting” sequence in the Focusing process.
MI3 has added two new acronyms DARN and CATS. Rather than reflecting malice towards our feline friends, they reflect a refinement of the concept of Change Talk that was introduced in the second edition of MI. MI3 divides Change Talk into preperatory change talk (p. 160) and mobilizing change talk (p. 161). Mary points out that this distinction is one of the most obvious research-informed changes to the model. DARN stands for Desire, Ability, Reason, and Need. When you hear people using this language you know they are preparing for change, but are not making the change.
In contrast, when you hear CATs language: Committment, Activation, and Taking Steps, you know that people are mobilized for change.
Mary ends with an exercise that gives people a quick taste of Motivational Interviewing.
There is something very “meta” about the fact that Motivational Interviewing as a model is changing. Right? I find some comfort in knowing that the people who have developed this way of addressing ambivalence and strengthening motivation to change, are themselves open to changing how they think about change. It would be hard to have much confidence in a model of change that always stayed the same. Ok. Enough pontificating. If you’re a longtime listener of the podcast you’ll know that I usually ask my guests for a list of resources. I didn’t do that this time because Motivational Interviewing, Third Edition is the best resource out there. Guilford Press has some free resources that include includes a more comprehensive bibliography of Motivational Interviewing, two annotated case examples, reflection questions for each chapter, the personal values card sort, and a glossary of Motivational Interviewing terms. The link is in the book and on the Social Work Podcast website. To learn more about Mary Velasquez, find links to related podcasts and other resources, or read the transcript, please go to socialworkpocast.com. If you like the podcast, please consider leaving a positive review on iTunes. If you want to connect with thousands of other fans of the podcast, go to our Facebook page at https://www.facebook.com/swpodcast. You can follow the Social Work Podcast on Twitter at @socworkpodcast. If you like to listen to the podcast on the go, consider using the Stitcher mobile app which allows you to stream the 10 latest episodes and share them with your friends and coworkers. Now, without further ado, on to episode 84 of the Social Work Podcast, Motivational Interviewing, 3rd Edition: Interview with Mary Velasquez, Ph.D.
InterviewJonathan Singer: Mary, thanks so much for being here on the Social Work Podcast and talking with us about motivational interviewing. My first question is, how did you get involved in motivational interviewing?
Mary Velasquez: Well, it's a bit of an interesting and kind of a roundabout story. When I was a young mom, staying at home with my kids, I was a smoker. Hate to admit that these days, but I was. And I wasn't feeling well one day. Called my mother over and asked her to help me with the kids. And just kind of one of those days where you're feeling good enough to kind of be knocking about the house, but not good enough to be doing your regular things. So I was looking at a newspaper, a little throw-away newspaper, and found an advertisement that said, "If you're a smoker and you don't want to quit, call this number." So just, really just for the heck of it I called the number and agreed to participate in a research study.
I stayed with that study. They followed me. I moved. The researchers kept calling me and kind of hounding me. And my husband would say, "Why are you doing this? Why are you staying with this study?" And I said, "You know, I'm not really sure." But I liked the questions they're asking me. There was never any kind of intervention or anything that I really had to do. And I said, "But they pay me $8." And he said, "Well, I'll pay you $8 to quit this study, because you're spending a lot of time on it."
Later on, I decided to go back and finish my college degree. I would like to go to graduate school. And I remembered that the psychologist that had done this study sent a little summary of the study to the participants, and I got it out and there was this thing about the stages of change and how people went about changing a behavior. It turned out the psychologist was Carlo DiClemente. And my professor said I really should get to know him, and perhaps volunteer in his lab.
Jonathan Singer: So are you saying that you were part of the classic smoking study, like the one that the Stages of Change model was developed out of.
Mary Velasquez: Well, yes. I am. It was, yes, it was Carlo. It might have even been his dissertation study. But it was Carlo DiClemente, and he was working with Jim Prochaska, and they had done, I think, some original work, but this was definitely one of the early studies. So I got up my courage and called this guy's office, and offered to volunteer in his research study, because I was very interested in going back to school. And the research assistant said, "Well, we don't really use volunteers." And then a few minutes later called back, and this was back before the days of institutional review boards, and she said, "Dr. DiClemente wants to know if you were in one of his research studies, because he recognized the name." I said, "Well, yes, in fact I was." And she said, "Yes, he'd love for you to come in." So I started working with him. He's just an amazing colleague, researcher, just a find person.
And continued through my finishing school, my master's degree. Went on to work as a project director for him. And then there was a large study called Project Match that was an alcoholism treatment matching study, one of the largest studies funded by the National Institutes for Health, and he asked me to be the project coordinator. So I worked with him on that. And right around that time he was working with Bill Miller, who was also a Project Match investigator, and just an amazing psychologist, really doing some very good work. And I learned about motivational interviewing really through those early days of working with Bill and Carlo. The transtheoretical model stages of change, and the other constructs, processes of change, were being really studied in a number of different settings.
And as we thought about this pre-contemplation and contemplation stage of change and how to move people forward, it turned out that motivational interviewing looked like just the thing to do. And Bill worked with the other investigators to write what's called Motivational Enhancement Therapy, which is a therapy manual based on motivational interviewing. So I trained in one of the early, Bill started doing this motivational interviewing. It's now called motivational interviewing network of trainers, but training in motivational interviewing, how to be a trainer. And so I went to that, and they, really the Stages of Change Transtheoretical Model and Motivational Interviewing are what Bill and Carlo call kissing cousins. They sort of grew up together.
So Bill and Steve Rollnick were developing Motivational Interviewing really right around the time. They incorporated the stages of change into their early work. And it was just a natural fit. So all of our research, I went on to...Carlo moved to the University of Maryland, and we continued to work together, and then I continued to write grants, moved to medical school as director of research in a family medicine department. We continued to work together and write grants, and now all of our grants incorporated motivational interviewing along with these stages of change and the rest of the transtheoretical model variables. And then stayed there, did research there, and then was recruited to the School of Social Work at the University of Texas at Austen. So that's kind of a...Told you it was a long story.
Jonathan Singer: What a great story. You'd never think that a sore throat could lead to something like that.
Mary Velasquez: And I did quit smoking along the way. I did, just because of all those questions they were asking me, I think. And really I think it, that's part of what research does is raises people's awareness.
Jonathan Singer: So the third edition of Motivational Interviewing has just come out. I understand there's some pretty big changes that are in the new edition, including a new definition of what motivational interviewing is. Could you tell us how it's changed?
Mary Velasquez: Sure. I think that one of the things that has made motivational interviewing as popular as it is, is that Bill Miller and Steve Rollnick have done an excellent job of keeping it alive, of growing along with their...As we learn more about motivational interviewing they revise the book. The do the research that really informs the field, and then they take the results of that research and apply it in new ways. So motivational interviewing today may look different. Fundamentally it's not different. But there were a lot of things that are evolving.
And so one of the things that is, I think, one of the biggest changes is that instead of having one set definition, they really sort of built these three definitions. One is sort of a lay person's definition, which I like the best. But it's really, it's about conversations about change. So basically they're really defining it as that. So the definition that I like is that motivational interviewing is the collaborative conversational style for strengthening a person's own motivation for and commitment to change. So basically it's a conversational style. So it's you and I are having a conversation. And a lot of what we've learned about motivational interviewing of late is that it has to do with language.
So as we talk about change, and as a really skillful person, or a really aware provider, colleague, physician, counselor, social worker talks about change, they're really paying attention to the client's language, and so it's a conversation. In motivational interviewing, they are looking at sort of a continuum. They talk about one way of working with a person is directing them. We tell people what to do, and that's been very common in treatment programs, particularly in addictions. We tell people what to do, and we tell them how they should do it. So that's one style.
Another style at the other end of the continuum is following. So we just kind of follow behind the person, letting them do whatever they want, go where they want to go, and we follow. But in between the directing style and the following style is really a style that's more about guiding. And you think about a good guide. Perhaps you're climbing Kilimanjaro. A guide is going to be there, perhaps offer advice, but not tell the person what to do, really, but sort of be there just to guide them and to help them. So a good motivational interviewing counselor, provider, is going to be more of a guide. And so in motivational interviewing it's not necessarily a situation where one person's the expert, and the other person is learning something. In fact, it's just the opposite, because it's the client that's the expert, or the person who's the expert about their own life.
And I'm talking about, because this is the Social Work Podcast, I'm using the term client and counselor or social worker. But it really is in all kinds, you know, these kinds of conversations happen every day, and we recognize in motivational interviewing that it's any conversation about change, really, where the person is listening and eliciting from the client their own ideas, perhaps reflecting back to them, helping them move forward toward change. That's good motivational interviewing. And you don't have to be necessarily a practitioner of some sort. You can do good motivational interviewing. It's a skill. It's not easy to learn, necessarily, but it's learnable, and lots of people do it in all kinds of professions, and can do it well. A good pastor often can do motivational interviewing. Physicians use it quite effectively. So I think that's the beauty of it, and I think that's why it's become so popular and so important.
Jonathan Singer: I think it's interesting you said that it's not easy. I think that one of the things that I've heard from students, or folks that don't know about motivational interviewing is, it doesn't look like their doing anything. Right? I'm watching this person, and it just seems like they're having a conversation, and where's the therapy. Where is the actual technique?
Mary Velasquez: That's a good question, because it often looks like a conversation, often looks effortless, when in fact, good motivational interviewing, there's a lot going on. The counselor, or the therapist, or the provider, is really thinking on their feet, listing for the client language. And they're listening from the person, again language about change. The recent work in motivational interviewing over the past, maybe the past decade, has identified what we call change talk. A lot of the work by Dr. Terry Moyers at the University of New Mexico, she's done a fabulous job of trying to figure out if motivational interviewing is so effective, and it is. Researcher is showing it's a very effective style. What is it about motivational interviewing? What's happening in that session?
And let me just digress for just a second here. There's some real problems with the way people typically "deliver" counseling. I think for many, many years, we trained, I'll go back, talk about social work students here. You know, we train people, and we tell them, "You know, when you go in, here's how you open." My students say, "We know how to open a session. We know how to terminate. We're taught how to terminate a session. But what do you actually do when you're there in the room with a client?" What Terry and Bill and Steve and others did, was look at successful clients, and they listened to therapy tapes of those sessions, and really tried to identity what was happening. They worked with a guy named Paul Amerhein, a psycholinguist, to sort of figure out what the client was saying, and what the therapist was saying to the client that really helped the person move forward.
So they identified these four areas of what we call change talk. The first is the desire to change. So the person is thinking about, I really want to do this. I want to change. The second is ability. I can do this. How might I go about it? Because unless a person really feels like they can do it, they have the confidence they can do it, they're not likely to change. The third is reasons. What are the reasons for a person to change? And then the need for change. So they use the acronym DARN. And then they talk about this change talk, this change language.
So that's what's happening in this session. A good motivational interviewing provider is listening for that change talk. And they're also listening for what we call sustain talk, so if a person is talking about the reasons for staying the same. So you're hearing ambivalence going on in that session. The person's talking about all the reasons, for example, that they shouldn't take their medication, or all the reasons that they are going to continue to smoke, or to drink. And then on the other hand, the desire, ability, reasons, and need for change. So as a skillful MI provider is listening to that, they begin to reflect the change talk, not ignoring this sustain talk, but reflecting the change talk. And as the person, as we hear more and more change talk, we also then begin to hear some commitment language from the client. So again, skillfully reflecting the change talk, leading up to commitment language, and that's really more of, I'm going to change. I'm going to do this. I promise I'll do it. I will do it.
So that's what's happening in that session. And the therapist, or the counselor is keeping track, really tracking what the client's saying, using different levels of reflection, maybe very simple reflection. Maybe just repeating what the client's saying, or changing the words slightly. And then more complex reflections, maybe some metaphors, really continuing the conversation and advancing, helping the person move toward change, but again using the client's own ideas about change. So there's a lot going on in that session, and a really good and really skillful person who's doing motivational interviewing is keeping up with all of that, and resisting the urge, what we call the riding reflex, where we often want to give advice. We all want to tell the person what to do. We say, "Oh, I'm really well trained. I know how to help you do that." And so as, again going back to the social work example, that's the thing when you say, often you hear people say, "What's really going on there? It just seems like it's a conversation."
Our students, what I do in my class is, the first part of it is really teaching them to listen, how to use good nonverbal behaviors, how to not use this riding reflex, and to have the students learn that they have to put aside, oftentimes, their own ideas about the client's change. A steep learning curve, sometimes, for us to undo those behaviors of wanting to fix people.
Jonathan Singer: So what are some examples of language that people might use to indicate that they're in those different places?
Mary Velasquez: Well, if you think about what we call sustain talk, that's basically when a person is staying sane. So "I have a lot of stress in my life, and if I were to quit smoking, I would just be anxious all the time. I'm just, I'm not ready to do that." So that's sustain talk. Identifying change talk, we use that acronym DARN, and you can identify it by, can you hear someone say, "I know I could do this." Or " Actually I think I can. I have a reason to do this. I want to." So that's that change talk. And the commitment language is really when someone says, "I will do this. I promise to do this. I am going to do this. I'm sure that I'll do this." And then there's another little piece that's just kind of taking steps, so when the person is really then beginning take action. So the acronym that's often used is DARN, and then DARN CATS. And in motivational interviewing, we use a lot of acronyms to help us remember things. So the DARN piece is that change talk, and then the CAT piece the commitment, and then the taking steps, or taking action.
Jonathan Singer: So this third edition is coming out with some changes. Could you talk a little bit about motivational interviewing the way that we have thought about it, and then just contrast it.
Mary Velasquez: Sure. Yeah. I think one of the bigger changes is that in the first Motivational Interviewing, the first two editions, we talked about, or we read about phase one and phase two of motivational interviewing. The example I remember that always stuck with me is that Bill and Steve talked about walking up a hill in snowshoes, and so you're helping the client really develop motivation as you walk up that hill. And then they get to the top and they kind of ski down the other side, and that part is easy. And in the latest edition, the third edition of Motivational Interviewing, they're really focusing not only on that building motivation, but what do you do when you get to the top of that hill. How do you help a client plan further change, and how do you elicit from their ideas about change, but then really help them think about how to move forward, and how to take action.
Jonathan Singer: And is that because providers were saying, "Okay, I'm actually pretty good at getting people up the hill, but then when they get there I kind of lose them," or there seem to be things that don't work, or maybe it's not quite as easy to ski down the hill as it seems. Is that why the changes happened?
Mary Velasquez: I think so. And I think that there were also some studies, including some of our own, that are showing that using the motivational interviewing strategies that we know to date can be very effective if you're helping a person who's not ready to change. And as they get closer to that change, if we continue to use those same motivational interviewing strategies, you know, we're kind of looking at decisional balance and really continuing to talk about reasons for change and why they should change and helping them see that, but they're ready, they're really ready to take action and we don't focus on that, then we can stall them. So really using other strategies, even some cognitive behavioral strategies, I think that has a lot to do with it.
Certainly in our own work, we've seen, we've done some research, for example, on groups, group motivational interviewing in groups, which is another interesting area. But in that work, people who came into the group, who were not ready to change, did very well in a motivational interviewing group. But those people who came in who were already ready to change, using the stages of change language that people in preparation perhaps, didn't do so well with motivational interviewing. And in fact, the people who were less ready, when we looked at them a year later, they had actually done better using the motivational interviewing approach than those people who came in ready to change.
So I think that's one of the things that Bill and Steve really have done a great job of focusing on, how do you really identify where the person is, and then use the strategies that are very appropriate for. They don't always use the language of states of change, but using strategies that are appropriate to where that person is on a continuum. You think about what they called a readiness ruler, on a scale of 0 to 10, how ready is that person to change, and then really tailoring to where they are.
Jonathan Singer: So it sounds like maybe there are not so many changes to the motivational interviewing concepts around working with people in pre-contemplation and contemplation and perhaps preparation, but it's more the action and maintenance that some of the changes are happening?
Mary Velasquez: Well, sort of. They're really, I think, refining their language. So they don't use the stages of change terminology in Mi3, but really they explain what they call these processes. So there are four of them. And the first one is engaging, where you're really developing the relationship with the client, listening, helping the client feel comfortable with you, developing that rapport, and so really calling that the first process in motivational interviewing, that engaging piece, paying a lot of attention to that.
And then the next piece is the focusing part. How do you help the client identify the actual behavior change? It could be, for someone who's diabetic, for example. They may be smoking. They may be eating unhealthfully. They may be not exercising. But how do you help them identify the area, talk about the one they're most ready to change, or perhaps the one that is causing them the most problems. If you're a health care provider, how do you focus. Oftentimes, that's where our students in social work get very lost. They follow the, they want to ask the client about their childhood, or they want to identify their depression or anxiety. They get all...It's one of the biggest things that we try to teach the students, when we teach them motivational interviewing, is how do you focus that session, and how do you focus it in a way that's most helpful to the client. And it's about where the client wants to go, but also an informed guiding process. So that's the second piece.
Jonathan Singer: So like if somebody comes in and they're diabetic, even though you might be really interested in their childhood and how they learned about food and their family history, that that might not necessarily be focusing the conversation on a behavior that they would change. Is that right?
Mary Velasquez: Yeah. It's exactly right. And we teach our students that typically you want to, as quickly as you can, identify a target behavior. And that doesn't mean that that won't change as you go through the session. And some behaviors are more amenable to that, of course, in a health care setting. And more and more of our students are becoming integrated health behavior specialists. And in that case, the students, you really want for them to identify, if they have 20 minutes with someone, what behavior should they focus on.
So often I'll say, for example, I teach them to use a strategy that Steve Rollnick explains in his Health Behavior Change book, where you draw several circles on a paper, and you say, it's called agenda setting. "Mr. Smith, with your health issues, often times different behaviors can lead to being diabetic, can contribute to diabetes. One might be smoking and one might be exercise. One might be diet. Let's write them in these little circles. And then what else might there be. You can see that some of these circles are blank. How would you fill this in? Now let's talk about these different behaviors. Which one of these might be most important to you? Or which one of these would you like to work on today?" Or, "As your counselor, it seems to me that this is an area that is causing the biggest concern. Would it be all right if we focus on this today?" So there's real, there's an asking permission. There's getting the client's concerns right there in front of you, so that's the focusing piece.
Jonathan Singer: Okay. So the first one is this engaging. And then the next one is the focusing. And that example that you just gave of the circles on the page. I mean it seems very concrete and collaborative and like a great way to set an agenda with somebody who might not be coming up with it.
Mary Velasquez: That's right.
Jonathan Singer: And so you said there's a third and a fourth thing?
Mary Velasquez: There are. The third is really more of an evoking or eliciting process. That's where the change talk that I was talking about earlier, that's where that comes in. So we're eliciting the client's own ideas about change. Oftentimes we use, one example is a strategy called elicit-provide-elicit. So you ask the person what they know. So, "Mr. Jones, what do you know?" Or Mr. Smith, I think it was, "What do you know about diabetes and what contributes to diabetes." And then learning from the client what they know about the behavior. And then, "Would it be all right? I have a few other pieces of information. Would it be okay if I talk with you about that?" And then coming back at the end. So that's the provide piece. And then coming back at the end and asking an open question. "What do you make of that?" Or, "What might you do now?"
So really eliciting, providing information advice in a way that the client is really part of the conversation. And then again, asking an open question at the end. Always listening for change talk. Always reflecting the change talk when you hear it. So that way the client, we hear it several times. You ask an open question. The client's response is often change talk. The counselor reflects that change talk. And then at the end of the session, in good motivational interviewing, they use summaries, and so you're summarizing, picking, Bill talks about it almost as building a bouquet, putting together a bouquet, so picking flowers, those change statements about change are the flowers that sort of form this bouquet, and then a summary. And so the client is hearing it again during that summary. So that's the eliciting piece. And that's a piece that really takes a lot of skill.
And in these studies about language, again what they hear is that the more change talk, the more often the client makes statements about change, there's an increased probability that the person will actually change. It's the change talk, but then also the commitment language. So it's the type of change talk as well. They just keep talking about change, that's good. But if you can help a client move forward into that commitment language piece, that's what's most predictive of long-term change.
Jonathan Singer: Yeah, I love the visual of the bouquet, in terms of a summary, really picking out those beautiful parts. That's nice.
Mary Velasquez: I did some training with some sheriffs from South Texas once, and they weren't quite as enamored with the bouquet [laughing].
Jonathan Singer: That sort of picking out the best magazine clip.
Mary Velasquez: I'm afraid so. And they were doing Motivational Interviewing and learning it, and actually doing it very, very well.
Jonathan Singer: That's interesting. So was that the fourth?
Mary Velasquez: No, that was the third?
Jonathan Singer: That was the third. Okay.
Mary Velasquez: And the fourth is really planning, so helping the person think about what they'll do. "If you make this change, when you make this change, who can help you do it? How will you know that it's working for you? What are some steps, very specific steps that you can take? How can you identify those resources? Are there people in your environment? Are there programs?" So really helping the person be very specific about what might be helpful to them.
Jonathan Singer: And so these four processes, would they occur in a single session, over multiple sessions? Is this something that, is there a time frame for it, or is it...I'll let you answer the question.
Mary Velasquez: Yeah, that's a very good question. And it varies depending on the client. In some cases, the client comes in really sort of ready for change. And rather than spending a lot of time in the session building, it's really helping the person to plan. And I think always that engagement piece sometimes, you always want to do that. You always want to develop the rapport with the client. You always want to elicit their own ideas about change. But some people are really ready to get down to the planning piece. So again, it depends on the client. If we don't pay attention to where the client is in the whole process of change, we're going to lose them pretty quickly. And a lot of times, the client will tell you you're doing a great job, and thank you very much, but they're not going to change.
And one of, I think, again, a strength of motivational interviewing, is not only can we identify and listen and hear these things happening in a session, but we're able to code them. So we can listen to a tape of a motivational interviewing session and identify, what is a what we call MI-adherent behavior. You know, the therapist is being supportive, asking permission. And non-adherent, so directing, telling the person what to do. So we actually score that. Open questions. Open questions are questions that can't be answered with a yes or a no, and really lead, help a person to think about all aspects of change, as opposed to a closed question. It's not always bad to ask a closed question, but we try to have many more open questions than closed.
So you can record that, the open to closed question ratio. You can note that during a session. You can listen for change talk. How much sustain talk did you hear where the person wasn't going to change, and then how much change talk did you hear? So you can record all that. You can track it. You can give feedback as a supervisor using what's called the Motivational Interviewing Treatment Integrity Coding System. I think that's the whole name of it. They call it the MITI. And then there's some other very good coding systems as well. But that is, it really looks like, according to the research, that you can record that change talk, and then you can really predict how well a person's going to do.
Jonathan Singer: So you talked about DARN CATS. And you talked about these four phases: engaging, focusing.
Mary Velasquez: Evoking.
Jonathan Singer: Evoking, and then planning. And really the way that you're talking about it actually answers that first question that I had really beautifully, which is, are they doing anything? I mean, clearly there is so much to do and so much to focus on, and to do it in a way that sounds like kind of a natural conversation I could see would be really, really require a lot of skill, a lot of training. Now one of the things we've talked about is health behaviors and things like that. Is there a place for motivational interviewing where there's not a concrete objective behavior, or even health behavior. What about like a social skill?
Mary Velasquez: That's one of the changes, again, in the Mi3 book. There's quite a bit written about when there is not a specific behavior change, how you would go about working in that situation. There's also a term that I really like. It's called equipoise. How you as a counselor keep a balance when you have an opinion about this client. So this kid, for example, you may have some thoughts about how this kid is behaving. What happens when it's a moral decision? So maybe this kid's parents, maybe you think this kid should be taken out of the home situation.
And as a social worker, I think you really have to be aware of, there are cases in which there is a favored outcome, and an important outcome, where you have an opinion. But in other cases, maybe not so much. Say a person is going to get, thinking about an abortion. Right? So can you keep your equipoise in that situation? When is there a time that you may not want to use motivational interviewing. Maybe it's inappropriate depending on your thoughts and your feelings, and really just knowing whether you can be in that situation as a social worker, using motivational interviewing, but using it well, and again keeping that what we call equipoise. There's a very nice section on that in the new book as well.
Jonathan Singer: So motivational interviewing has changed, it sounds like, in response to research and maybe therapists' feedback. I'm wondering. Are there concepts that we think of as being classic motivational interviewing that are maybe not emphasized so much anymore? They're ideas that are on the outs, or not emphasized? Because you've talked about some of the things that are being introduced, being emphasized.
Mary Velasquez: Yeah. Well, one area is the stages of change, for example. Early on I think people got kind of confused between the stages of change and motivational interviewing. They sort of saw that as being the same thing. And in Mi3, there's much less of an emphasis on the stages, and more of an emphasis on change sort of being on a continuum. Another example is decisional balance. We typically think of that as every motivational interviewing session should have looking at the pros and looking at the cons. And in the new conceptualization, there's really less emphasis on the sustained talk, on looking at the pros of the current behavior. Certainly you wouldn't do away with that, but much more of an emphasis on looking at the change as opposed to doing an equal decisional balance.
Jonathan Singer: And why is that?
Mary Velasquez: Well, I think there has been, again they're doing a really good job of relying on the research. And when I say "they," I mean Bill and Steve, the originators of the model. I mean Terry Moyers, who has done, again, a lot of the research, and all of us in the motivational interviewing network of trainers. Many of us have research studies. We've published the findings, and they really paid attention to that. It's a changing. Your Mi3 is going to look somewhat different from the original Motivational Interviewing. Again, the spirit is very important, focusing on the client's autonomy, and the collaborative aspect of it, the evoking piece. That's all still there. There's nothing that's really gone from motivational interviewing, and I wouldn't say anything's really even on the outs. But it's developing.
I think another thing that's been exciting is an emphasis on groups, motivational interviewing in groups. There's some new work. Chris Wagner and Karen Ingersoll recently published a book on MI in groups, and how do you take these concepts and do...Motivational interviewing can be tough with one person. Think about doing it with eight or nine or 10. Linda Sebelle talks about it as conducting a symphony. Mark and Linda Sebelle have done some tremendous work on combining motivational interviewing with cognitive behavioral therapy. They have a new, very nice treatment manual out. So a lot of those things have been developing. The original researchers, I think, have done a nice job of paying attention to those things as they've come along.
Jonathan Singer: It's exciting, because I know that one of the things that I talk about with my students, and one of the things actually that Joe Walsh said in an interview with him on theories for clinical practice, is that students, they read about theories, clinical practice theories, and they think, "This is how it is." And they don't think, "I could provide feedback on whether or not this actually fits my client's situation. It should, according to the theorist, or the author. But when I apply it, it doesn't really fit." And what you're saying is that Miller and Rollnick, and the rest of you who were involved in this as researchers, really are saying, "Yes, feedback is good. And if it's not working, let's change it." Which I think is amazing.
Mary Velasquez: Yeah. One of my favorite lines from Carrie is, "You know, we just made this stuff up." We are learning as we go. On a personal note, I have to say, these folks are good people who listen and want to help people improve their lives. And they don't take themselves too seriously. Other people may take them very seriously, and they do great work. But they're not afraid to say, "Oh, you know, well maybe our thinking about that needs to shift a little bit." Steve Rollnick oftentimes gets frustrated with us as specialists. Sometimes we Americans want answers to everything pretty quickly. I think that it's evolving, and that's the beauty of the motivational interviewing approach, is it continues to evolve, continues to grow, and sometimes those ideas that we thought were so clever in the beginning and so right on track are moved aside in favor of new ideas.
Jonathan Singer: So we've talked a lot about motivational interviewing, the changes in Mi3, a lot of the concepts. If there was only like 15 minutes to give an example of what motivational interviewing looks like, what would you say? What would you do?
Mary Velasquez: Well, Bill Miller uses an example that I really like. He calls it "taste of Mi." So he'll ask a group, he'll ask them to role play. And first he'll have them try to convince a person to change, and give them all the reasons that they need to change. Of course, that's the non-motivational interviewing style. And then his taste of motivational interviewing, he just has people ask the following questions: Why would you want to make this change? How might you do this to succeed? What are your three best reasons for doing this? How important is it to you? And now what do you think you'll do? That taste of MI really gives people a stark contrast between that first approach, that is the convincing, telling, advising, and then the second one that is motivational interviewing. There's much more to it than that, but clearly that gives, if you had 15-20 minutes, that's the thing I would do.
Jonathan Singer: That's great. Mary, thank you so much for taking the time to talk with us about motivational interviewing, and to share your deep, deep experience on this. Especially because, as of this recording, the third edition of MI just came out. So really, really appreciate you doing this.
Mary Velasquez: Thanks, Jonathan. I really enjoyed it. It was fun.
Jonathan Singer: Hey, it's me again. I know, you're waiting for the klezmer music. Just a couple of things, and then I'll put it back on for you. So if you're a long-time listener of the podcast, you'll know that I usually ask my guests for a list of resources. And you'll also notice that I didn't ask Mary. Because, Motivational Interviewing, 3rd Edition, is the best resource out there. Now, Guilford Press has some free resources that include a more comprehensive bibliography of Motivational Interviewing, two annotated case examples, reflection questions for each chapter, the personal values card sort, (I don't really know what that is) and a glossary of motivational interviewing terms. And the link to those free resources is in the Motivational Interviewing book, and it's also on the Social Work Podcast website.
Now if you want to learn more about Mary, or to find links to related podcasts and other resources, or read the transcript, you can go to SocialWorkPodcast.com. If you like the podcast, please consider leaving a positive review on iTunes. The more positive reviews, the easier it is for folks to find it. And if you want to connect with the thousands of other fans of the podcast, you can go to our Facebook page, at Facebook.com/swpodcast. You can follow the Social Work Podcast on Twitter @socworkpodcast. And if you like to listen to the podcast on the go, you could consider downloading the Stitcher mobile app, which allows you to stream the 10 latest episodes and share them with your friends and coworkers.
Okay. You've been really patient. Here's your klezmer music.
[outro] I'm Jonathan Singer, and thanks for being with me today for another episode of the Social Work Podcast. If you missed an episode, or have suggestions for future episodes, please visit SocialWorkPodcast.com. If you'd like to support the podcast, please visit our online store at CafePress.com/swpodcast. To all the social workers out there, keep up the good work. We'll see you next time at the Social Work Podcast.
Transcription service provided by Rev.com
References and Resources
- Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing, Third Edition: Helping People Change. New York, NY: Guilford Press.
- Motivational Interviewing (3rd Edition) Companion Website: Includes a more comprehensive bibliography of Motivational Interviewing, two annotated case examples, reflection questions for each chapter, the personal values card sort, and a glossary of Motivational Interviewing terms.
- Singer, J. B. (Producer). (2009, October 10). Prochaska and DiClemente's Stages of Change Model for Social Workers [Episode 53]. Social Work Podcast [Audio podcast]. Retrieved from http://socialworkpodcast.com/2009/10/prochaska-and-diclementes-stages-of.html
- Singer, J. B. (Producer). (2007, February 12). Person-centered therapy [Episode 8]. Social Work Podcast [Audio podcast]. Retrieved from http://socialworkpodcast.com/2007/02/person-centered-therapy.html
- Velasquez, M. M. (2001). Group treatment for substance abuse: A stages-of-change therapy manual. New York: Guilford Press.
- Velasquez, M. M., Ingersoll, K. S., Sobell, M. B., Floyd, R. L., Sobell, L. C., & von Sternberg, K. (2010). A dual-focus motivational intervention to reduce the risk of alcohol-exposed pregnancy. Cognitive and Behavioral Practice, 17(2), 203–212. doi: 10.1016/j.cbpra.2009.02.004
- Velasquez, M. M., von Sternberg, K., & Parrish, D. E. (2013). CHOICES: An integrated behavioral intervention to prevent alcohol-exposed pregnancies among high-risk women in community settings. Social Work in Public Health, 28(3-4), 224–233. doi: 10.1080/19371918.2013.759011
APA (6th ed) citation for this podcast:
Singer, J. B. (Producer). (2013, September 11). #84 - Motivational Interviewing, 3rd Edition: Interview with Mary Velasquez, Ph.D. [Audio Podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2013/09/MI3.html