I have said before (and say on my front page) that “therapy isn’t rocket science” and I mean it. it isn’t the hardest thing in the world, but it does require some savvy. It takes experience (some lived and some learned), patience, and a little dab of tenacity in order to become a proficient helper. It often also takes a little skill in helping people get motivated to start healing. Unfortunately, as I’ve learned, many students come away from the various schools of helping education ill-prepared to face the challenges brought on my clients who may be unaware of their problems (or the need to change them).
There Is No One Secret Sauce…
I’ve had the good fortune of being able to teach at the University of Utah College of Social Work for the last semester. In addition to my work there as a Field Practicum Supervisor, I’ve been fortunate enough to work with 20 students for the last semester in teaching them the basics of Substance Use Disorder treatment, including the American Society for Addiction Medicine’s Patient Placement Criteria.
Subsequently, I was offered the option to present on a topic of my choice to the Substance Use Disorder Counselor class of 2020, and the topic I chose was “The Secrets of Motivational Interviewing.” I chose this topic because I believe every new graduate should have the nuts and bolts of how to help others change and that such knowledge shouldn’t be a mystery.
…But There Are Secret Ingredients
Actually, they’re not that secret, if you know where to look. Sadly, many new helping professionals are not introduced to the concept of Motivational Interviewing, let alone given a course in how to actually do it. Many students know “of” MI, but very little about it otherwise. So, when I chose to present on this topic, I referred two a couple of documents I’ve come to know well in the last while, the Motivational Interviewing Treatment Integrity Coding Manual and SAMHSA’s Treatment Improvement Protocol (TIP) 35.
In Part I of this two-part post, I’m going to focus on the specific behaviors clinicians can learn and practice, as defined by the Motivational Treatment Integrity Coding Manual, in order to become more proficient Motivational Interviewers. In Part II, I will be going over specific techniques and interventions (many of which are covered below) that clinicians can use to help those they serve move through the Stages of Change, as defined by Prochaska and DiClemente’s Transtheoretical Model of Change.
Know MITI, Be MITI
I was fortunate enough to take an online training in the Motivational Interviewing Treatment Integrity Coding Manual during the Winter of 2017-2018 (side note, the training is being offered again in January of 2020, by the same trainers Dr. Jennifer Frey and Ali Hall, J.D.). During this training, several other First Step House employees and I learned the ins and outs of Motivational Interviewing (MI). Specially, we learned how to listen to a 20-minute segment of a recorded session and score how well a clinician did in using MI. The MITI scores two main areas: a “Global Rating” that determines an overall impression of the segment and “Behavior Counts” that rates specifically how the clinician did in using MI Adherent behaviors and avoiding MI Non-Adherent behaviors.
The MITI Coding Manual (Moyers, et al., 2015), available free of charge, is a validated instrument that was produced from the Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico. In it, the above topics are covered great detail. I will mention them briefly here, but would encourage readers to delve into he document further themselves.
MITI Global Scoring
As I mentioned, the MITI helps coders create a Global Rating for the overall “impression” of the recorded conversation’s content. The Global Rating Encompasses 4 main areas: Cultivating Change Talk, Softening Sustain Talk, Partnership, and Empathy. By simply understanding the importance of each of these areas, new clinicians instantly improve their MI prowess. Scoring in each these areas is on a Likert Scale of 1-5, the details of which are covered in the manual intself.
The following are definitions for each, taken directly from the manual.
Cultivating Change Talk
This scale is intended to measure the extent to which the clinician actively encourages the client’s own language in favor of the change goal, and confidence for making that change. To achieve higher ratings on the Cultivating Change Talk scale, the change goal must be obvious in the session and the conversation must be largely focused on change, with the clinician actively cultivating change talk when possible. Low scores on this scale occur when the clinician is inattentive to the client’s language about change, either by failing to recognize and follow up on it, or by prioritizing other aspects of the interaction (such as history-taking, assessment or non- directive listening). Interactions low in Cultivating Change Talk may still be highly empathic and clinically appropriate.
Softening Sustain Talk
This scale is intended to measure the extent that the clinician avoids a focus on the reasons against changing or for maintaining the status quo. To achieve high scores, clinicians should avoid lingering in discussions concerning the difficulty or undesirability of change. Although therapists will sometimes choose to attend to sustain talk to build rapport, in general they should spend only as much time as needed to bring the discussion into more favorable territory for building motivation. High scores may also be achieved in the absence of sustain talk during a session, if the clinician does not engage in behaviors to evoke it. Low scores in Softening Sustain Talk are appropriate when clinicians focus considerable attention to the barriers of change, even when using MI-consistent techniques (e.g., asking open questions, offers reflections, affirmations and other MI Adherent techniques) to evoke and reflect sustain talk throughout the session.
This scale is intended to measure the extent to which the clinician conveys an understanding that expertise and wisdom about change reside mostly within the client. Clinicians high on this scale behave as if the interview is occurring between two equal partners, both of whom have knowledge that might be useful in solving the change under consideration. Clinicians low on the scale assume the expert role for a majority of the interaction and have a high degree of influence in the nature of the interaction.
This scale measures the extent to which the clinician understands or makes an effort to grasp the client’s perspective and experience (i.e., how much the clinician attempts to “try on” what the client feels or thinks). Empathy should not be confused with sympathy, warmth, acceptance, genuineness, support, or client advocacy; these are independent of the Empathy rating. Reflective listening is an important part of this characteristic, but this global rating is intended to capture all efforts that the clinician makes to understand the client’s perspective and convey that understanding to the client.
Clinicians high on the Empathy scale show evidence of understanding the client’s worldview in a variety of ways including complex reflections that seem to anticipate what clients mean but have not said, insightful questions based on previous listening and accurate appreciation for the client’s emotional state. Clinicians low on the Empathy scale do not appear interested in the client’s viewpoint.
MITI Behavior Counts
The MITI classes behaviors into two distinct groups: MI Adherent Behaviors and MI Non-Adherent Behaviors. Simply put, the MITI tells clinicians exactly what to do and what not to do. MITI conversations are broken into “volleys,” (basically, a whole exchange between the clinician and the recipient) and subsequently, volleys are assigned a behavior count code. I’ll spare the technical details in this point, again directing readers to the Coding Manual itself, but the below are taken directly from the document.
Giving Information (MI Adherent)
This category is used when the interviewer gives information, educates, provides feedback, or expresses a professional opinion without persuading, advising, or warning. Typically, the tone of the information is neutral, and the language used to convey general information does not imply that it is specifically relevant to the client or that the client must act on it.
Questions (MI Adherent)
All questions from clinicians (open, closed, evocative, fact-finding, etc.) receive the Question code but only one question per volley is coded. Thus, if a clinician asked four separate questions in a single volley, only one question would be tallied. Closed and open questions are not differentiated. Instead, coders attend to the nature of the clinician’s questions with the global ratings in mind. For example, many fact-finding questions within an interview mightresult in a lower rating on the Partnership global and reduce opportunities to Sidestep Sustain Talk.
Simple Reflections (MI Adherent)
Simple reflections typically convey understanding or facilitate client–clinician exchanges. These reflections add little or no meaning (or emphasis) to what clients have said. Simple reflections may mark very important or intense client emotions, but do not go far beyond the client’s original statement. Clinician summaries of several client statements may be coded as simple reflections if the clinician does not use the summary to add an additional point or direction.
Complex Reflections (MI Adherent)
Complex reflections typically add substantial meaning or emphasis to what the client has said. These reflections serve the purpose of conveying a deeper or more complex picture of what the client has said. Sometimes the clinician may choose to emphasize a particular part of what the client has said to make a point or take the conversation in a different direction. Clinicians may add subtle or very obvious content to the client’s words, or they may combine statements from the client to form summaries that are directional in nature.
Affirmations (MI Adherent)
An affirmation (AF) is a clinician utterance that accentuates something positive about the client. To be considered an Affirm, the utterance must be about client’s strengths, efforts, intentions, or worth. The utterance must be given in a genuine manner and reflect something genuine about the client. It does not have to be focused on the change goal and could reflect a “prizing” of the client for a specific trait, behavior, accomplishment, skill, or strength. Affirms are often complex reflections, and when this occurs, the Affirm code should be preferred.
Seeking Collaboration (MI Adherent)
This code is assigned when a clinician explicitly attempts to share power or acknowledge the expertise of the client. It can occur when the clinician genuinely seeks consensus with the client regarding tasks, goals or directions of the session. Seeking collaboration may be assigned when the clinician asks what the client thinks about information provided. When permission to give information or advice is sought, Seeking Collaboration is typically assigned.
Emphasizing Autonomy (MI Adherent)
These are utterances that clearly focus the responsibility with the client for decisions about and actions pertaining to change. They highlight clients’ sense of control, freedom of choice, personal autonomy, or ability or obligation to decide about their attitudes and actions. These are not statements that specifically emphasize the client’s sense of self-efficacy, confidence, or ability to perform a specific action.
Persuade (MI Non-Adherent)
The clinician makes overt attempts to change the client’s opinions, attitudes, or behavior using tools such as logic, compelling arguments, self-disclosure, or facts (and the explicit linking of these tools with an overt message to change). Persuasion is also coded if the clinician gives biased information, advice, suggestions, tips, opinions, or solutions to problems without an explicit statement or strong contextual cue emphasizing the client’s autonomy in receiving the recommendation.
Confront (MI Non-Adherent)
This code is used when the clinician confronts the client by directly and unambiguously disagreeing, arguing, correcting, shaming, blaming, criticizing, labeling, warning, moralizing, ridiculing, or questioning the client’s honesty. Such interactions will have the quality of uneven power sharing, accompanied by disapproval or negativity. Included here are instances where the interviewer uses a question or even a reflection, but the voice tone clearly indicates a confrontation.
Know Better, Do Better
As a Social Worker, I often act as a gatekeeper. My job is to protect the profession and the people I serve, sometimes judging who can become a Social Worker and who can not. Yes, there are secrets to be kept and Copyrights to respect, but with the ever-growing shortage of skilled professionals in the helping workforce, new and tenured clinicians alike need to know the basics of good therapy. That knowledge, thankfully, is available to all.
There’s a funny thing that happens when people realize that the gap between where they truly are vs. where they think they are; that is they almost can’t help but begin to close it. Dissonance itself, when identified, becomes reason to change and improve and it is my hope that by sharing this information simply and openly, practitioners who come to know better, will do better. So now you know better…
I’m happy to offer a consulting service and work with others on improving their clinical skills. Though I cannot purport to know anything about the realm of Quantum Mechanics, I do know that simply watching something, changes it. Atoms and people alike, change state when observed and my experience has been that simply observing others consistently helps them change. If you’d like to chat about coaching, please see my Clinical Supervision and Consulting page.
Until next time…
Moyers, T.B., Manuel, J.K., & Ernst, D. (2015). Motivational Interviewing Treatment Integrity Coding Manual 4.2.1. Unpublished manual.