**[Motivational Interviewing]{.underline}**

![](media/image1.wmf){width="0.5048611111111111in"
height="0.4479166666666667in"}***A. [Set the Agenda
Together]{.underline}***

-   **Open the Conversation - Ask Permission**

> Asking permission is a powerful counseling tool. It reminds us to keep
> the focus on the participant, encourages the participant to take an
> active role, and minimizes the possibility of resistance. Permission
> language implies that the participant has choices and she is more
> likely to initiate a change in behavior. [Asking permission sounds
> like]{.underline}:
>
> *Would it be alright to talk about ­­\_\_\_\_\_?* or
>
> *Would you be interested in exploring with me some of the ways you
> might\_\_\_\_\_?*
>
> The participant is more likely to hear and accept your advice if you
> have permission to give it.

-   **Set the Agenda Together (Circle Chart)**

> Using the Circle Chart involves you and the participant in a
> collaborative exercise that maximizes participant choice. The same
> could be accomplished using a set of open-ended questions, but the
> chart can be used as a time-saving aid. The circle chart illustrates a
> range of health behaviors that you and/or the participant feel are
> important. (You can cross out any pre-filled ones that do not apply.)
> Do not use the chart as a checklist which might lead to premature
> focus on one behavior when in a hurry. Using it as a checklist also
> loses the spirit of motivational interviewing. [Introducing the Circle
> Chart sounds like:]{.underline}
>
> *On this chart here are some things that affect your/your child's
> health. How do you feel about these? Are you ready to think about
> changing any of them? These blank circles are for any other things
> which you think might be of greater concern to you today. What do you
> think? What would you like to talk about today?*
>
> or
>
> *Here are some of the things which affect people's health. What do you
> think? I wonder whether you might be interested in talking about any
> of these topics? Or do you have other health or nutrition concerns
> today?* (pointing to blank circles) *You are the best judge of what to
> consider changing.*
>
> ![](media/image2.wmf){width="0.5048611111111111in"
> height="0.5048611111111111in"}***B. [Explore Readiness to
> Change]{.underline}***

-   **Assess Readiness to Change (Ruler)**

> Once the participant has expressed a concern or identified a topic,
> you can use the readiness ruler to find out which behavior she feels
> is important today and most ready to talk about. If the participant
> brings up another [unrelated concern]{.underline}, your challenge is
> to listen carefully and advise (if advice is wanted), and then decide
> where to go next. After a couple of minutes of careful listening, park
> the discussion. Maybe write it down in one of the circles.
> [Redirecting the conversation might sound like]{.underline}:
>
> *We have talked about \_\_\_\_\_, and I can understand why this must
> be bothering you.*
>
> *Would you be happy to move on to talk about \_\_\_\_ (original
> topic)?*
>
> To assess readiness, get into a curious state of mind. It is important
> to be genuinely interested in what the participant is saying. Use your
> active listening and critical thinking skills while you ask probing
> questions. You want to learn exactly how the person feels about the
> chosen topic. [These probing questions might sound like:]{.underline}
>
> *Which of these do you feel most ready to think about changing?*
>
> or
>
> *What exactly are you saying about \_\_\_\_\_ (i.e. your child's
> appetite and using a bottle)? How ready do you feel to talk about
> changing them, or would you prefer to leave it for the time being?*
>
> or
>
> *Thinking about getting more exercise, where would you place yourself
> on this line? Some people are not at all ready, some are very ready,
> and others are somewhere in between. How do you feel at this moment?*
>
> Summarize your understanding of the outcome and be prepared for the
> participant to: (1) not be interested in changing any behavior
> (discussion ends here);
>
> \(2\) be willing to change a behavior; or
>
> \(3\) be ambivalent about changing a particular behavior.
>
> The back of the ruler sheet provides additional guidance.

-   **Explore Mixed Feelings about Change (Ambivalence)**

> If the participant is unsure (in the middle of the ruler), explore
> mixed feelings with her. You can use the ruler sheet to list and
> discuss the costs and benefits for changing and not changing. [Sharing
> the pros and cons list might sound like:]{.underline}
>
> *You can see that, for all people who are unsure about change, there
> are pros and cons of staying the same* (the present behavior), *as
> well as making a change. Have you ever thought about it like this?
> Would you like to spend a few minutes talking about it now?*
>
> or
>
> *Would you like to spend a few minutes talking about \_\_\_\_\_looking
> at what you like and don't like about it?*
>
> or
>
> *Sometimes it can be helpful to examine the pros and cons
> of\_\_\_\_\_. Would you like to spend a few minutes doing this, or
> would you prefer not to?*
>
> Your role is to provide structure, listen carefully and summarize. The
> participant's role is to explain to you how she really feels. It is
> important that you validate the benefits of not changing to elicit
> "change talk" from the participant. [This might sound
> like:]{.underline}
>
> *What are the good things about change?*
>
> *Why is this?*
>
> *How will it affect you?*
>
> Then, follow-up with:
>
> *What are the not-so-good things about change?*
>
> *What won't you like?*
>
> *How will this affect you?*
>
> Whenever the participant begins to talk about changing a behavior,
> take every opportunity to keep the momentum going! Restate it back to
> the participant. At the same time, you will be building rapport,
> increasing the importance of the change as well as increasing her
> confidence in her ability to change.
>
> ![](media/image3.wmf){width="0.5826388888888889in" height="0.41875in"}
> ***C. [Take the Next Step]{.underline}***

-   **Provide Education or Give Suggestions**

> When providing education, emphasize the principles and convey the
> 'spirit' of motivational interviewing. [This sounds like:]{.underline}
>
> *There is usually more than one possible course of action.*
>
> *I can tell you about what's worked for other people.*
>
> *You are the best judge of what works for you.*
>
> *Let's go through some of the ideas/strategies together.*
>
> Identify a number of ideas/strategies, if possible. Brainstorm
> together and explore the barriers.
>
> *I have some ideas about how you could\_\_\_\_\_. Would you like to
> hear about them now? What ideas can you suggest?*
>
> When it is an idea based on your expertise, it may be useful to frame
> it as what has worked for other people. [This might sound
> like:]{.underline}
>
> *Some people in your situation have found it useful to\_\_\_\_\_.*
>
> *What do you think suits you best? What do you think you can/could
> do?*
>
> *Which one makes the most sense to you?*
>
> When you feel something else is more important, or she says something
> that you strongly disagree with, remember that it is the participant's
> choice. Acknowledging that she *could* do something will increase her
> willingness to listen to *your* opinion. Always ask permission before
> giving it. An empathetic counselor shows respect for the participant's
> perspective, so remember to show empathy throughout. Be careful not to
> assume that the person is more ready than she actually is. This can
> bring up resistance in the participant. [Resistance sounds
> like:]{.underline}
>
> *Yes, but... or Well, I guess I could try.*
>
> Body language can look like reluctance, so be observant. When
> resistance surfaces, back off and come alongside your participant.
> [Addressing resistance might sound like:]{.underline}
>
> *I can tell I've gotten us off track here. Can we go over again what
> is important to you right now?*
>
> or
>
> *I agree, there's no point in trying something that's not going to
> work.*
>
> or
>
> *I sense you aren't ready to work on this right now. That's fine. This
> is your session.*
>
> *I'm hearing you feel two ways about this.*

-   **Ask about the Next Step (Set Goal Together)**

> Talk together about goals and strategies. Let the participant choose
> what is best for her and her family. When she sets a goal/strategy,
> let her know that she can adjust her strategy based on what is and is
> not working. Changing habits and establishing a new lifestyle takes
> time and is a gradual process. Some people can handle dramatic
> all-or-nothing type changes, but others do better with gradual changes
> (one small step at a time). [Setting goals might sound
> like:]{.underline}
>
> *You are worried about your family's reaction if you start cooking the
> food with less fat -- would you prefer to introduce this gradually to
> avoid problems?*
>
> Failing to make action plans does not mean that the contact has
> failed. Do not push the participant too far. Time spent with you can
> often lead to action taken independently at a later point. Acknowledge
> and ask about participant concerns, don't ignore them. [Probing for
> concerns sounds like:]{.underline}
>
> *Before we move on, is there anything that particularly concerns you
> about the thought of making this change?*
>
> *or*
>
> *What happened last time you tried and how will it be different this
> time?*
>
> Seize opportunities that strengthen your participant's commitment by
> listening for "change talk." "[Change talk" sounds like:]{.underline}
>
> *I'll think about it; I might, I'll try, I could. (shows weak
> commitment)*
>
> or even better...
>
> *I will; I'm going to; I promise; I'll do my best. (shows stronger
> commitment)*

-   **Close on Good Terms - Summarize and Express Confidence**

> Summarize the participant's desire, ability, and reasons for change.
> Briefly acknowledge reluctance, if appropriate. Summarize the strength
> of the participant's commitment. If their commitment seems strong,
> have her leave with a good plan in place.
>
> Encourage your participants to see themselves as competent, determined
> people who
>
> are potentially able to make changes but have not yet hit on a
> successful plan for doing so.
>
> *"When we think of failure; Failure will be ours. If we remain
> undecided; Nothing will ever change. All we need to do is want to
> achieve something great and then simply do it. Never think of failure,
> for what we think, will come about." \~Maharishi Mahesh Yogi*