MOTIVATIONAL INTERVIEWING

IN SOCIAL WORK PRACTICE

 APPLICATIONS OF MOTIVATIONAL INTERVIEWING
Stephen Rollnick, William R. Miller, and Theresa B. Moyers, Series Editors
Since the publication of Miller and Rollnick’s classic Motivational Interview-
ing, now in its third edition, MI has been widely adopted as a tool for facilitat-
ing change. This highly practical series includes general MI resources as well
as books on specific clinical contexts, problems, and populations. Each volume
presents powerful MI strategies that are grounded in research and illustrated
with concrete, “how-to-do-it” examples.

Motivational Interviewing in Health Care: Helping Patients Change Behavior

Stephen Rollnick, William R. Miller, and Christopher C. Butler

Motivational Interviewing in the Treatment of Anxiety

Henny A. Westra

Motivational Interviewing, Third Edition: Helping People Change

William R. Miller and Stephen Rollnick

Motivational Interviewing in Groups

Christopher C. Wagner and Karen S. Ingersoll, with Contributors

Motivational Interviewing in the Treatment

of Psychological Problems, Second Edition
Hal Arkowitz, William R. Miller, and Stephen Rollnick, Editors

Motivational Interviewing in Diabetes Care

Marc P. Steinberg and William R. Miller

Motivational Interviewing in Nutrition and Fitness

Dawn Clifford and Laura Curtis

Motivational Interviewing in Schools:

Conversations to Improve Behavior and Learning
Stephen Rollnick, Sebastian G. Kaplan, and Richard Rutschman

Motivational Interviewing with Offenders: Engagement, Rehabilitation, and Reentry

Jill D. Stinson and Michael D. Clark

Motivational Interviewing and CBT:

Combining Strategies for Maximum Effectiveness
Sylvie Naar and Steven A. Safren

Building Motivational Interviewing Skills: A Practitioner Workbook, Second Edition

David B. Rosengren

Coaching Athletes to Be Their Best: Motivational Interviewing in Sports

Stephen Rollnick, Jonathan Fader, Jeff Breckon, and Theresa B. Moyers

Motivational Interviewing for Leaders in the Helping Professions:

Facilitating Change in Organizations
Colleen Marshall and Anette Søgaard Nielsen

Motivational Interviewing in Social Work Practice, Second Edition

Melinda Hohman
 MOTIVATIONAL
INTERVIEWING
IN SOCIAL WORK
PRACTICE
Second Edition

MELINDA HOHMAN
Series Editors’ Note by Stephen Rollnick,
William R. Miller, and Theresa B. Moyers

The Guilford Press

New York London
 For William and Olivia

Copyright © 2021 The Guilford Press

A Division of Guilford Publications, Inc.
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www.guilford.com

All rights reserved

Except as noted, no part of this book may be reproduced, translated,

stored in a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED DUPLICATION LICENSE

This material is intended for use only by qualified professionals.

The publisher grants to individual purchasers of this book nonassignable permission

to reproduce Figure 10.1. This license is limited to you, the individual purchaser, for
personal use or use with clients. This license does not grant the right to reproduce
the material for resale, redistribution, electronic display, or any other purposes
(including but not limited to books, pamphlets, articles, video or audio recordings,
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The author has checked with sources believed to be reliable in her efforts to provide
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that are accepted at the time of publication. However, in view of the possibility of
human error or changes in behavioral, mental health, or medical sciences, neither the
author, nor the editors and publisher, nor any other party who has been involved in
the preparation or publication of this work warrants that the information contained
herein is in every respect accurate or complete, and they are not responsible for any
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Library of Congress Cataloging-in-Publication Data is available from the publisher.

ISBN 978-1-4625-4563-6 (paperback)
ISBN 978-1-4625-4564-3 (hardcover)
 About the Author

Melinda Hohman, PhD, MSW, is Professor and Director Emeritus in the

School of Social Work at San Diego State University. Before retiring in 2018,
she taught courses in social work practice, substance abuse treatment, and
motivational interviewing (MI), at both the graduate and undergraduate
levels. Dr. Hohman’s research interests include substance abuse assessment
and treatment services and the learning of MI. She has been a member of
the Motivational Interviewing Network of Trainers (MINT) since 1999,
training community social workers, child welfare workers, probation offi-
cers, and addiction counselors, among others, across the United States and
internationally. She has served as a MINT Trainer of Trainers.

v
 Series Editors’ Note

Social work and motivational interviewing (MI) just seem to belong

together. At the heart of social work is a desire to empower people, to
find and call upon their own strengths and abilities. Social workers accom-
plish this primarily through talking, and a skillful sensitivity to language
is central in MI. Components of the underlying spirit of MI converge with
core values of social work: a compassionate empathy for those we serve, an
accepting and collaborative partnership, and a proactive intention to call
forth the best in others.
MI began as a way to help people find their way out of alcohol prob-
lems, but it soon became apparent that this counseling style has much wider
applicability. It is now being used in a broad range of professions around
the world. MI is particularly useful in situations where people want or need
to make a change and are ambivalent about doing so. The change might
be in behavior, attitude, or lifestyle. Part of them knows that change is
important, and another part is reluctant. They want it and they don’t want
it simultaneously. That is a very normal human dilemma. Ambivalence is,
in fact, one step forward on the road to change, and MI helps people keep
moving down that road.
MI is not about fixing people. It does not come from a deficit view that
people are lacking something that we have to install. Ultimately people are
free to choose what they will do and how they will be. MI is about helping
people find their own personal motivation for positive change, which leads
naturally to planning and connecting them with the resources needed to
accomplish it. That facilitator role is home territory for social workers.

vi
 Series Editors’ Note vii

Obviously the first edition of Motivational Interviewing in Social

Work Practice was very well received, because here is the second edition!
This time, there are only two “guest authors” (in Chapter 9), and Dr.
Melinda Hohman’s seasoned voice shines throughout. She has a long and
deep understanding of MI and how it is used in day-to-day practice. We are
grateful for her contribution of this integrated and updated volume, and
hope that it will stimulate further creativity and research in the applica-
tions of MI in the broad range of services that social workers provide.

                      Stephen Rollnick, P h D

                      William R. M iller, P h D
                     Theresa B. Moyers, P h D
 Preface

I was delighted when the editors of the Applications of Motivational Inter-

viewing series asked me to update and revise this book. Not long after we
had published the first edition of this book, the third edition of Motiva-
tional Interviewing: Helping People Change (Miller & Rollnick, 2013) was
released and contained new information about the authors’ thinking on
motivational interviewing (MI). Changes in knowledge and practice were
based on updated research, practice experiences, and many conversations
with MI practitioners.
I have found the new content to be valuable in my teaching of MI to
social work students, and the new edition of this book reflects my own
learning, thinking, and updated research about important and emerging
topics regarding the use of MI in social work practice, as presented in
Chapters 1 and 2. The four processes and discord, introduced by Miller
and Rollnick in 2013, are addressed with new social work case vignette and
dialogue examples, in Chapters 3 through 8. Chapter 9 presents updated
information regarding how to implement MI in everyday social work prac-
tice, including coaching and other new technology-delivered methods. New
applications of MI, framed by critical race theory, along with the Grand
Challenges of Social Work, trauma, food insecurity, and environmental
social work practice, are introduced in Chapters 10 and 11. Chapter 12
offers tips on teaching or training of MI.
At the beginning of each chapter, I have included the relevant Edu-
cational Policy and Accreditation Standards (EPAS) from the Council on
Social Work Education (CSWE). These competencies were written by the

viii
 Preface ix

profession’s accrediting body and are used in social work education for
both graduate and undergraduate students (CSWE, 2015). They help guide
curriculum to assure that students can meet these standards at graduation.
At the end of each chapter you will find application questions that can be
used by both social work students and practicing professionals to deepen
their learning and engagement with the issues, concepts, and techniques
discussed.
Another new aspect of this book is the inclusion of “voices from the
field”—narratives written by social workers regarding how they use MI in
the contexts of their everyday work. The authors are diverse voices who
represent the topics of each chapter based on their area of social work prac-
tice. What has been especially meaningful for me is that the majority of
these authors are my former students, and I am so pleased to see how they
have taken what they learned about MI into their many different and won-
derful careers.
This book is being completed in the midst of a pandemic. We have no
idea how this will end but it is certainly changing social work practice and
education. Technology has allowed social workers to meet with clients via
their laptops (if they have them) and educators, to teach online. MI train-
ers are finding new skills in leading interactional learning exercises in the
electronic classroom. The pandemic, however, has also exacerbated and
highlighted the racial, economic, and other social inequities in our society.
Many people are out of work and many are food insecure. Social work
has a large role to play in confronting these inequities and helping people
recover from the trauma of this experience. I believe MI will be a major
aspect in the healing process as social workers assist clients, first respond-
ers, medical professionals, and the bereaved.
Whether you are new to MI or are already an MI practitioner, I hope
you find this new edition thought provoking and useful in your career jour-
ney as a social worker.

Acknowledgments
Writing a book like this takes a village. I am thankful for the feedback,
knowledge, support, and ideas from the series editors, Drs. Stephen Roll-
nick, William Miller, and Theresa B. Moyers. I am appreciative of the care-
ful editing by Guilford Press editors Jim Nageotte and Jane Keislar. I am
grateful for the contributions from various social workers, all making a
difference, who agreed to write for this book: Thank you to Debbie Boer-
baitz, Jacqueline Fajardo, Sarah Feteih, Claudia Gonzalez, Jesse Jonesberg,
Soraiya Khamisa, James Kowalsky, Yuen Lam Shek, Angel Tadytin, Maria
Villegas, Christopher Walker, and Marya Wright, for sharing your stories
x Preface

as well as for providing feedback on individual chapters. Thank you to con-

tributors Cristine Urquhart and Fredrik Eliasson, who wrote about their
work implementing MI in large organizations.
Members of MINT who were always available and willing to read
a chapter and give feedback include Stephen Andrew, Elizabeth Barnett,
Steve Berg-Smith, Rosalind Corbett, Ali Hall, Dr. Christine Kleinpeter,
Ken Kraybill, Adrienne Lindsey, Dr. Hilda Loughran, Dr. Bill Matulich,
Vincent Schutt, Liz Silverman, and Dee Dee Stout. Other colleagues who
were helpful that I would like to thank are Dr. Julie Altman, Erin Cros-
bie, Dawn Gibbins-McWayne, Dr. Maria Gwadz, Norman Jackson, Jaymi
Matranga, Dr. Audrey Shillington, and Dr. Geoff Twitchell. Finally, I want
to thank my husband, Jerry, and my family for their encouragement and
willingness to listen when I needed to “think out loud” during the writing
process.

A Note on Language
I have made every effort to use gender-neutral pronouns (they/their/them)
throughout the book. The only exceptions are examples that refer to spe-
cific individuals.
 Contents

PART I. INTRODUCTION
Chapter 1 Why Social Work and Motivational Interviewing? 3
Chapter 2 The “How” of Motivational Interviewing 25

PART II. ELEMENTS OF

MOTIVATIONAL INTERVIEWING
Chapter 3 The Engaging Process: Building Trust 45
Chapter 4 Focusing: A Conversation about a Conversation 66
Chapter 5 Evoking: Change Talk as the Driver of Change 80
Chapter 6 Client Discord: A Time to Re-Engage 103
Chapter 7 Sharing Information and Advice 120
Chapter 8 Planning: Determining the Path Forward 138

PART III. IMPLEMENTATION

Chapter 9 Integrating Motivational Interviewing 157
into Social Work Practice
with Cristine Urquhart and Fredrik Eliasson
xi
xii Contents

Chapter 10 Motivational Interviewing through the Lens 181

of Critical Race Theory
Chapter 11 Innovative Applications 204
of Motivational Interviewing
Chapter 12 Teaching and Training Motivational Interviewing 224

References 233

Index 275

Purchasers of this book can

download and print an enlarged
version of Figure 10.1 at
www.guilford.com/hohman-forms
for personal use or use with clients
(see copyright page for details).
 PA RT I
Introduction
 C hapte r 1

Why Social Work

and Motivational Interviewing?

EPAS 1: Demonstrate Ethical and Professional Behavior

 Use reflection and self-regulation to manage personal values and
maintain professionalism in practice situations.
EPAS 4: Engage in Practice-Informed Research and Research-Informed
Practice
 Use and translate research evidence to inform practice, policy, and
service delivery. (Council on Social Work Education [CSWE],
2015, pp. 7, 8)

Social workers love to talk. And it is a good thing we love to do it. Other
than the dreaded paperwork, it is what we do all day long: interview clients,
consult with colleagues, meet with families, present cases at team meetings,
go to lunch with a friend, and perhaps teach a class of social work students.
Though social workers work in many different kinds of settings, we have
in common that we spend most of our time talking.
We think we are pretty good at talking; why, we have been doing it
for years! No one has to teach us how to communicate. Sure, we learned
a bit about interviewing skills in social work school and, as students, we
watched our field instructors interact with clients. But for the most part,
as in parenting, we tend to rely on communication skills we developed in
growing up and have used all along.
Sometimes, though, as social workers, we run into clients that we find

3
4 INTRODUCTION

particularly challenging, and it seems the usual methods of communica-

tion aren’t that helpful. Clients may be angry, argumentative, or apathetic,
seeming to have no desire to change despite being on an obvious (to us)
destructive course. When this happens, it is easy for any of us to try to
persuade or even argue with clients. Sometimes we feel responsible for our
clients and the outcome and react by trying to fix the problem. It feels like
if we could only give them enough information, ask the right questions, or
lay out the consequences of a particular action, then clients would be open
to change or at least, to calm down. This can especially occur in situations
that have a dire outcome, such as in child welfare or probation (Mirick,
2013). A recent study of social workers working in child protection in the
United Kingdom found that even after being trained in motivational social
work skills/motivational interviewing (MI; described below), they dem-
onstrated lower levels of empathy and listening. They challenged parents
and became the expert when they felt child safety issues were too great
(Wilkins & Whitaker, 2017). They felt extremely responsible for making
sure their clients made the right choices, and resorted to providing direc-
tion for change.
Often the context or the culture of our practice setting influences how
we communicate (Forrester et al., 2018). My first job was working in juve-
nile probation, and my role models there taught me how to be direct and
blunt. From there I worked in adolescent substance use treatment, where
the model at that time was to be directive and challenging until clients
accepted the label of alcoholic or drug addict. This confrontation was seen
as necessary for clients to break through their denial and admit to a prob-
lem. Counselors, probation officers, and social workers in both of these
settings were viewed as experts who had the answers and had to warn,
admonish, threaten, or advise. This was taking the usual or directive com-
munication method to an extreme.
Although I was able to utilize the directive style fairly well, a part of
me was always a bit uncomfortable with this style, as it seemed so removed
from what I was taught in my Bachelor of Social Work and Master of Social
Work programs regarding the values of the social work profession: service,
respect for the client, nonjudgmental posture, client self-determination,
dignity and worth of the person, and the importance of human relation-
ships. Besides advocating for social justice and working across systems,
social workers are called to work as partners with their clients, to recog-
nize and emphasize their clients’ strengths, and to assist clients in meeting
their own needs (International Federation of Social Work [IFSW], 2018;
National Association of Social Workers [NASW], 2017). Social workers by
nature seem to be drawn to humanistic approaches.
It was entirely by happenstance that I discovered MI. I became a
social work educator in 1995, and a few years later was looking for addi-
 Why Social Work and MI? 5

tional resources for the substance abuse course I was teaching to graduate
students. I came across Motivational Interviewing: Preparing People to
Change Addictive Behavior (Miller & Rollnick, 1991) and found that the
concepts and methods described in it for working with those with sub-
stance use problems were much more congruent with social work values as
well as with my own personal value system. Bill Miller, one of the authors
of the book, has stated that many clinicians recognize MI when they meet
it, “not as something strange that they are encountering for the first time,
but as if it were something that they have known deeply and for a long
time, like an old friend” (Miller, 2013, p. 15). Not only was MI intuitively
appealing to me, but at that time strong research to support it was begin-
ning to accumulate. I immediately began to integrate MI into my classes,
and students responded well to it. I began to think of other areas of prac-
tice where MI might be useful, and applied it to child welfare work for
substance using parents, as I was quite interested in this area (Hohman,
1998). I was trained as an MI trainer in 1999 and integrated MI concepts
and skills into my social work practice skills courses. With strong support
of MI as an evidence-based practice, and like other schools of social work
across the country, my school now offers both undergraduate and graduate
courses that are strictly about MI.

What Is MI?

MI has been defined as “a collaborative, goal-oriented style of communi-

cation with particular attention to the 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” (Miller & Rollnick, 2013,
p. 29). MI has been framed as a guiding style of communication as com-
pared to a more directive style (Miller & Rollnick, 2013) and is based
on relational skills (MI spirit, described below) as well as technical skills
(described in Chapter 3) (Miller & Moyers, 2017). Initially developed as
an alternative to the confrontational and advice-giving methods of alcohol
use disorder treatment, it has been expanded and applied to a variety of
health-related behaviors and other concerns. In social work journals alone,
at least 33 research studies regarding MI were published between 2000 and
2016 (Egizio, Smith, Wahab, & Bennett, 2019). Motivation to change is a
ubiquitous characteristic of most behavioral concerns; thus, social workers
have studied or applied MI in a variety of areas, as shown in Table 1.1.
MI is a style or way of being with clients, as well as a set of specific
skills that are used to convey empathy and encourage clients who are ambiv-
alent to consider and plan change. Building on the work of Carl Rogers’s
6 INTRODUCTION

TABLE 1.1. Social Work Research and Publications on MI by Topic

• Adolescents in school settings (Kaplan, Engle, Austin, & Wagner, 2011;
Hartzler et al., 2017; Sayegh, Huey, Barnett, & Spruijt-Metz, 2017; Smith,
Hall, Jang, & Arndt, 2009)
• Adolescent substance use (Blevins, Walker, Stephens, Banes, & Roffman, 2018;
Smith, Ureche, Davis, & Walters, 2015)
• Advance care planning (Ko, Hohman, Lee, Ngo, & Woodruff, 2016; Nedjat-
Haiem, et al., 2018; Nedjat-Haiem, Cadet, & Amatya, 2019)
• Alcohol and other drug treatment (Cloud et al., 2006; Gallagher, 2018; Jasiura,
Hunt, & Urquhart, 2013; Singh, Srivastava, & Chahal, 2019)
• Alcohol misuse in the military (Walker et al., 2017)
• Assertive Community Treatment teams (Manthey, Blajeski, & Monroe-DeVita,
2012)
• Child welfare (Barth, Lee, & Hodorwicz, 2017; Forrester et al., 2018; Hohman
& James, 2012; Jasiura, Urquhart, & Advisory Group, 2014; Shah et al., 2019)
• Colorectal screening (Menon et al., 2011; Wahab, Menon, & Szalacha, 2008)
• Coming-out process (McGeough, 2020)
• Contraception use (Whitaker et al., 2016)
• Deradicalization (Clark, 2019)
• Driving under the influence (DiStefano & Hohman, 2007)
• Group work (Jasiura et al., 2013)
• Health care reform (Stanhope, Tennille, Bohrman, & Hamovitch, 2016)
• HIV/AIDS transmission reduction and care (Gwadz et al., 2017; Murphree,
Batey, Kay, Westfall, & Mugavero, 2019; Picciano, Roffman, Kalichman, &
Walker, 2007; Rebchook et al., 2017; Rutledge, 2007; Velasquez et al., 2009)
• Interprofessional education (Tajima et al., 2019)
• Intimacy and sexuality (Tennille & Bohrman, 2017)
• Intimate partner violence (Dia, Simmons, Oliver, & Cooper, 2009; Hughes &
Rasmussen, 2010; Lauri, 2019; MI and Intimate Partner Violence Workgroup,
2010; Wahab, 2006; Wahab et al., 2014)
• Leadership (Wilcox, Kersh, & Jenkins, 2017)
• Medical student education (Engel et al., 2019)
• Exercise for patients with multiple sclerosis (Smith et al., 2010)
• Older adults (Cummings, Cooper, & Cassie, 2009)
• Parent–school engagement (Frey et al., 2019)
• People experiencing homelessness (Crouch & Parrish, 2015)
• Probation and reentry (Clark, 2006; Stinson & Clark, 2017)
• Prevention of fetal alcohol spectrum disorders (Urquhart & Jasiura, 2010)
• Refugee resettlement (Potocky, 2016; Potocky & Guskovict, 2019)
• School-based applications (Frey, Lee, Small, Walker, & Seeley, 2017)
• Screening, brief intervention, and referral to treatment (SBIRT) (Cochran &
Field, 2013; Topitzes et al., 2017)
                               (continued)
 Why Social Work and MI? 7

TABLE 1.1. (continued)

• Social work education (Greeno, Ting, Pecukonis, Hodorowicz, & Wade, 2017;
Hohman, Pierce, & Barnett, 2015; Iachini, Lee, DiNovo, Lutz, & Frey, 2018;
Pecukonis et al., 2016; Smith, Hohman, Wahab, & Manthey, 2017; Tennille,
Bourjolly, Solomon, & Doyle, 2014)
• Suicide intervention (Hoy, Natarajan, & Petra, 2016)
• Systematic review on social work outcomes (Boyle, Vseteckova, & Higgins,
2019)
• Training MI (Schwalbe, Oh, & Zweben, 2014)
• Transgender women of color (Rebchook et al., 2017)
• Trauma-informed care (MI and Intimate Partner Violence Workgroup, 2010;
Poole, Urquhart, Jasiura, & Smylie, 2013)
• Vocational rehabilitation/supported employment (Manthey, 2013; Manthey,
2009; Manthey, Jackson, & Evans-Brown, 2011)
• Young women who are homeless (Wenzel, D’Amico, Barnes, & Gilbert, 2009)

client-centered therapy (Rogers, 1951), MI is based on four aspects that

constitute the spirit of MI: compassion, collaboration, evocation, and
acceptance (Miller & Rollnick, 2013). In the third edition of their book on
MI, Miller and Rollnick (2013) expanded acceptance to include absolute
worth, autonomy support, accurate empathy, and affirmation. All of these
are attitudinal with their corresponding behavioral elements.
Let’s take a look at what these terms mean. Compassion was new to
the third edition of Miller and Rollnick’s book (2013). Miller (2017) defines
compassion as “not a feeling like sympathy so much as an intention: to
alleviate suffering and contribute to the well-being of others” (p. 22), and
it includes prioritizing clients’ needs over one’s own. Why this emphasis on
compassion? Miller and Rollnick (2013) added this concept as they believe
that some of the skills of MI (guiding a conversation, evoking the client’s
thoughts and ideas) could also be used in other settings, such as in sales.
The idea of compassion as serving clients’ needs above one’s own is to place
MI in the therapeutic realm. But in looking at this definition, isn’t alleviat-
ing suffering the main reason many of us go into social work? That part
is easy to understand. Prioritizing clients’ needs and/or goals seems like it
should be a given, but this isn’t always the situation (Wilkins & Whitaker,
2017; Zanbar, 2018). As Miller and Rollnick (2013) noted, sometimes per-
sonal or institutional/agency/organizational concerns may get in the way.
You may get distracted in a meeting with a client or family, thinking about
all the errands you have to run on the way home from work or a problem in
your own life, thus taking the focus away from them. A client may choose a
path that you disagree with and you may get into an argument about what
you think is best for them. You may work in a setting that puts pressure on
8 INTRODUCTION

social workers regarding the number of clients who must be seen each day,
or the number of times clients are allowed to meet with the social worker,
or the types of problems and goals that must be discussed. A supervisor
may insist that certain clients be seen only in a group setting due to staff
shortage, instead of selecting the modality that best serves the client.
The collaboration aspect of the MI spirit suggests that social workers
are seen as partners working with clients to understand their goals, motiva-
tors, and ambivalence around certain behavior changes. Social workers are
not experts but guides. We can provide information or advice, but in MI, it
is done with clients’ consent. It is assumed that clients have what they need
to make changes.
Grant Corbett, a social worker, calls this the competence worldview,
as compared to the deficit worldview (Corbett, 2009). In the deficit world-
view, social workers view their clients as not having the resources, skills, or
characteristics to make changes. Clients need to have these things given or
instilled in them. They lack insight or knowledge, and we, as expert social
workers, need to give them information, advise them, or teach skills. We
social workers can operate from the deficit worldview even when using the
strengths perspective (Corbett, 2009; Mirick, 2016; Saleeby, 2006)—by
unconsciously indicating to clients that if we work hard enough, we will
find the hidden strengths they have—that is, it is up to us, the experts, to
discover them. In the competence worldview, clients are seen as already
having the resources and characteristics they need, and it is our task to
evoke from clients their thoughts, ideas, abilities, knowledge of their own
strengths, and ways to change.
The aspect of evocation supports our eliciting or drawing out from
clients their thoughts and ideas regarding goals and methods of change.
Clients are not seen as being in denial but as wrestling with ambivalence
regarding changing a certain behavior. Ambivalence is defined as having
“simultaneous conflicting motivations” (Miller & Rollnick, 2013, p. 157)
and is viewed as normal. Exercise and diet are always good examples of
ambivalence! Think of your own relationship with these two health prac-
tices. In class, I ask students (or trainees when in the community) how
many have ever joined a gym. Lots of hands go up. Then I ask, “Who
joined but never went?” The response is lots of laughter and lots of hands.
We discuss the reasons for wanting to join a gym and also for not going
or only going sporadically. In MI, we evoke from the client his or her own
motivations for change, which are often the positive reasons for change,
known as change talk in MI. We may talk about the reasons for not chang-
ing (sustain talk) but tend to limit it or be selective in how we evoke it. We
will look at evoking change talk more in Chapter 5 and why to be cautious
about sustain talk.
The fourth aspect of MI is acceptance, which comprises absolute
 Why Social Work and MI? 9

worth, autonomy support, accurate empathy, and affirmation (Miller &

Rollnick, 2013). Absolute worth involves valuing each client (even despite
difficult or horrific behaviors that have brought them to our attention as
social workers) along with the belief in their potential to change (Rosen-
gren, 2018). Autonomy support is the understanding that clients themselves
are ultimately the ones who make decisions to change. We cannot force
them to do anything, not even with warnings or threats or with unsolicited
advice or education. Autonomy support, as is noted in Chapter 2, treats
clients as knowledgeable and insightful into their own situations, which
aids in increasing therapeutic alliance (Stinson & Clark, 2017). Think of
when a friend made suggestions to you regarding a course of action, or
when you were told what to do by someone: your autonomy got taken away
and most likely you reacted negatively. Or at least you weren’t too pleased!
You may not always agree with choices clients make, but keep in mind that
clients are more prone to push back or prove their own autonomy when
you communicate with them by giving advice, threats, warnings, and/or
consequences (Magill et al., 2014; Miller & Rose, 2009; Mirick, 2012).
When clients are on a destructive path, it is hard to resist the desire to fix
the problem—by doing for them, or by warning or threatening. This desire
(the righting reflex) is discussed further in Chapter 3.
Accurate empathy is another element of acceptance. This involves truly
listening to understand our clients’ perspectives and conveying this under-
standing back to them through reflective listening. Research has found that
the use of accurate empathy by social workers and other therapists, despite
their treatment orientation, is one of the strongest predictors of positive
outcomes (Gerdes & Segal, 2011; Moyers & Miller, 2013). Accurate empa-
thy is a skill that can be taught and measured (Gerdes & Segal, 2009;
Miller & Moyers, 2017; Mullins, 2011; Teding van Berkhout & Malouff,
2016). Empathy and reflective listening are examined further in Chapter 3.
Affirmations occur when the social worker comments on clients’
strengths or resources, which Stinson and Clark (2017) indicate is a way of
demonstrating that the social worker prizes the absolute worth of the cli-
ent. Different from praise, affirmations are more often behavioral or value-
focused. Instead of saying, “I’m proud of you,” the social worker may com-
ment, “It is important for you to be loyal to your family and put their needs
ahead of your own. You did that when you took on a second job. It isn’t
easy working so many hours.” Obviously, the social worker needs to know
the client fairly well, through careful listening, before an affirmation can be
made (Miller & Rollnick, 2013). Affirmations are another way to develop
hope as well. We will look more at affirmations in Chapter 3.
Are there any times when MI shouldn’t be used? If a client has already
decided to change, MI may not be needed, although the MI planning pro-
cess using client-centered listening skills can be helpful. It is unethical for
10 INTRODUCTION

a practitioner who has a personal or professional vested interest in an out-

come (such as wanting a teen client to give a child up for adoption) to
use specific motivational strategies (Miller & Rollnick, 2013). Use of MI
by police or even military counter-terrorism interrogators to obtain infor-
mation has drawn some ethical scrutiny by MI trainers and practitioners,
although it has been proposed as useful in the area of effective commu-
nication in moving a person away from violence or suicide (Clark, 2019;
Rollnick, 2014).
Can we use MI in crisis situations? While there is not much research
in this area, some are indicating that it is possible (Loughran, 2011). MI
has been found to be effective as a method to intervene with suicidal clients
to engage in safety planning, including means restriction, and in discus-
sion of the client’s ambivalence about living (Britton, Bryan, & Valenstein,
2016; Britton, 2015; Britton, Patrick, Wenzel, & Williams, 2011; Britton,
Williams, & Conner, 2008; Zerler, 2009). Using MI helps to build client
autonomy and promotes self-efficacy to “make ‘good choices’ about ‘bad
feelings’ ” (Zerler, 2009, p. 1208).

Why Use MI in Social Work Practice?

Social workers, and other helping professionals, as noted above, seem to

be drawn to MI for a variety of reasons (Corcoran, 2016; Loughran, 2019;
Wahab, 2005b). The five main reasons appear to be that (1) the aspects and
values in MI are similar to those that guide and are embraced by profes-
sional social workers; (2) MI has a rich body of evidence that supports its
use with populations at risk and the other types of clients who typically
interact with social workers; (3) MI has been found to be effective in clients
from diverse backgrounds and settings and seems to fit well with concepts
of cultural competency and cultural humility; (4) MI has been found to
blend well with other types of interventions; and (5) MI may be helpful in
reducing burnout.

Social Work Principles and MI Aspects

While there are social work codes of ethics in a variety of countries around
the globe, most have the common themes of social workers being commit-
ted to social justice, serving diverse and marginalized populations, practic-
ing with integrity, promoting client self-determination, maintaining confi-
dentiality, and using science to guide practice (IFSW, 2018). Scheafor and
Horejsi (2015) have synthesized much of this work into 24 common social
work principles, with 17 of them being focused on those that guide practice
work with clients.
 Why Social Work and MI? 11

MI is a method to use when what we hope for is behavior change.

Table 1.2 lists those social work principles that would be most closely
related to the type of work where MI would be used, and to the relevant
aspects of MI and the MI spirit. The social work principles include dignity,
respect, individualization, vision, client strengths, client participation, self-
determination, and empowerment. All of these principles are consistent
with the MI spirit of compassion, evocation, acceptance, and collabora-
tion. Because MI is based on client-centered theory and approaches, clients
are seen as the experts on their lives, with the role of the social worker
being to collaborate on looking at ideas, thoughts, and ways of addressing
client-identified concerns. An MI interview looks deceptively simple, as
our clients do most of the talking; we are busy evoking the clients’ per-
spective as well as keeping track of the responses for selected reflections
and summaries. We may give advice but only with permission to do so,
and typically advice is embedded in a menu of options that clients might
choose from. Clients make their decisions regarding behavior change and
how this will be accomplished, with their own determined methods. This
helps build client empowerment and self-determination.

MI as an Evidence-Based Practice and the Evidence-Based Process

As indicated earlier, codes of ethics have called on social workers to uti-
lize science or research evidence in determining the best interventions for
individual clients. The United States’ accrediting body for schools of social
work, the CSWE (2015), requires that students learn how to use the best
available evidence in their work (see EPAS 4 at the opening of this chapter).
This is a change from the previous paradigm of authority-based practice,
which valued tradition, experience, and advice from colleagues or super-
visors. Funders and state care systems are requiring social workers and
counselors in agencies to be trained in and utilize evidence-based practices,
some specifying MI (Miller & Moyers, 2017; Mullen & Bacon, 2006; Proc-
tor, 2006; Rubin & Babbie, 2017). There are several resources for social
workers to utilize, such as the California Evidence-Based Clearinghouse
for Child Welfare (CEBC, 2018) and the Cochrane Collaboration (2011).
All have information about MI and practices that incorporate MI as part
of the intervention. The CEBC utilizes a scientific rating scale to determine
how supported an intervention is by research. On the CEBC website (www.
cebc4cw.org/program/motivational-interviewing), MI for parental sub-
stance abuse has the highest rating or a “1,” indicating it is “well-supported
by research evidence” (CEBC, 2018). The Cochrane site (www.cochrane.
org) provides systematic reviews of research of applications of MI to vari-
ous topics, such as tobacco cessation.
Currently there are over 1,200 studies (mostly randomized controlled
12 INTRODUCTION

TABLE 1.2. The Relationship between Social Work Principles and MI Aspects
Social work principles
(Scheafor & Horejsi, 2015) MI aspects (Miller & Rollnick, 2013)
The social worker should treat MI spirit involves accepting the absolute worth
the client with dignity. of each client, working collaboratively with
clients as equal partners.

The social worker should MI spirit involves evoking from clients their
individualize the client. unique views and thoughts on their concerns.

The social worker should MI is based on client-centered theory and

consider clients experts on their approaches that value the knowledge that
own lives. clients have about their own lives. With
compassion, social workers prioritize clients’
needs over their own aspirations for clients.

The social worker should lend The social worker evokes hope and confidence
vision to the client. for change by discussing the client’s past
successes and ideas for how change is to occur.
Affirmations focus on the strengths the social
worker or clients see in themselves.

The social worker should build In a competence worldview (Corbett, 2009),

on client strengths. the task in MI is for the social worker to
determine what clients see as their strengths,
resources, or abilities, and how positive change
has occurred in the past.

The social worker should In an MI interview, the client should be doing

maximize client participation. the majority of the talking, with the social
worker practicing accurate empathy and
supporting client autonomy. Collaboration
means that change plans are created based on
clients’ needs and desires.

The social worker should Advice is given with client permission and
maximize client self- is provided within a menu of options. Client
determination. capability and autonomy are emphasized
regarding making choices.

The social worker should help MI can be combined with other methods as
the client learn self-directed needed, such as cognitive-behavioral therapy, if
problem-solving skills. the client wants to learn problem-solving skills.

The social worker should Supporting client autonomy and the belief
maximize client empowerment. in their abilities helps empower clients to
ultimately be the ones to make decisions about
their own lives.
 Why Social Work and MI? 13

trials) of the use of MI to address various health and other behavioral

changes (for a partial listing, see the MI website, www.motivationalinter-
viewing.org) and about 180 meta-analyses. The meta-analyses indicated
small to medium effect sizes with variation in findings. Although MI has
not been applied to every area of human concern, the broad application
and depth of research in some areas are appealing to social workers who
are looking to integrate evidence-based practice into their work. Models of
how to do this through the evidence-based process stress the need to search
for and critically appraise research and other information about specific
interventions, perhaps by using the websites listed above, and to include the
client in the decision making regarding which interventions to use (Gam-
brill, 2006). This could be done in an MI-congruent manner; however, MI
should not be used to influence a client to move in a particular direction
regarding the selection of an intervention. As in any review of research, a
critical examination should be given to the fidelity of the intervention and
in this case, if and how the use of MI was measured (Jelsma, Mertens,
Forsberg, & Forsberg, 2015).

MI as a Cross-Cultural Practice
Since the publication of the first edition of Motivational Interviewing
(Miller & Rollnick, 1991) and as research support across cultures has accu-
mulated, MI has been adopted by social workers and other helping profes-
sionals from around the world. Miller and Rollnick’s third edition (2013)
has been translated into 28 languages, and there are over 55 languages rep-
resented among MI trainers (W. Miller, personal communication). The use
of MI as an intervention has been studied with diverse clients in the United
States and beyond, for instance, with:

• African Americans regarding health behaviors (Befort et al., 2008;

Boutin-Foster et al., 2016; Chlebowy et al., 2015; Gross, Hosek,
Richards, & Fernandez, 2016; Ogedegbe et al., 2007; Resnicow et
al., 2001, 2008); depression and intimate partner violence (Wahab
et al., 2014); and experience of MI as an intervention (Madson,
Mohn, Schumacher, & Landry, 2015), among others.
• Native Americans regarding alcohol use and HIV testing (Dicker-
son, Brown, Johnson, Schweigman, & D’Amico, 2016; Foley et al.,
2005; Gilder et al., 2011; Komro et al., 2015; Villanueva, Tonigan,
& Miller, 2007).
• American Latinx who received interventions for alcohol use (Field et
al., 2015; Lee et al., 2013; Lee et al., 2019), smoking cessation (Bor-
relli, McQuaid, Novak, Hammond, & Becker, 2010), and psycho-
14 INTRODUCTION

tropic medication adherence (Añez, Silva, Paris, & Bedregal, 2008;

Interian, Martinez, Rios, Krejci, & Guarnaccia, 2010).
• Asian Americans to increase substance use treatment engagement
(Yu, Clark, Chandra, Dias, & Lai, 2009).
• International settings such as China, Colombia, India, Sweden,
Tanzania, Taiwan, Thailand, Uganda, and Vietnam (Arkkukangas
& Hultgren, 2019; Dow et al., 2018; Huang, Jiao, Zhang, Lei, &
Zhang, 2015; Hutton et al., 2019; Kiene, Bateganya, Lule, & Wany-
enze, 2016; Lin et al., 2016; Reyes-Rodríguez et al., 2019; Rongka-
vilit et al., 2015; Singh et al., 2019).

One important study of MI, a meta-analysis of 72 research studies, gave

empirical support for MI as being effective cross-culturally: treatment
effects were almost double for (U.S.) minority clients across the studies
than for nonminority clients (Hettema, Steele, & Miller, 2005).
Sue, Sue, Neville, and Smith (2019) indicate that the three major compe-
tencies in multicultural counseling include awareness, knowledge, and skills.
Awareness means having knowledge of one’s own personal biases and values,
along with being open, curious, and appreciative of those of our clients. We
acknowledge that diverse clients may have an entirely different worldview
and experiences from our own, and in social work terms, we also pay atten-
tion to the macro environment. Knowledge is regarding our understanding of
racism, institutional barriers, cultural aspects (in general) of diverse clients,
and of counseling methods. Skills include communication such as reflective
listening, accurate empathy, advocacy, ability to individualize clients (not
making assumptions that all clients from a certain group are the same).
In my classes on MI, I love to ask students (who are always very
diverse) why they think MI is so effective cross-culturally. The answers
come quickly. The appeal of MI as a communication method that can be
used in various cultures may be due to its focus on the recognition and
utilization of the individual values, goals, and strategies of the client, curi-
osity about the client’s worldview and lived experiences, and respect for
the client’s autonomy (Hettema et al., 2005; Interian et al., 2010; Madson
et al., 2015; Tsai & Seballos-Llena, 2019; Venner, Feldstein, & Tafoya,
2007). In MI, we suspend our own thoughts, goals, and values, and focus
on intensely listening to and reflecting those of our clients. Motivations and
strategies for change are evoked from the client and are not imposed by us
(Miller & Rollnick, 2013; Miller, Villanueva, Tonigan, & Cuzmar, 2007).
Minority clients may experience those who are from the majority culture as
paternalistic when we impose goals and strategies based on our worldview
(Sue et al., 2019). No matter what our race or ethnicity, in MI we strive to
work against being the “experts” who provide knowledge and skills, for
this only continues to perpetuate racism and power differentials, particu-
 Why Social Work and MI? 15

larly with clients from oppressed groups (Sakamoto & Pitner, 2005). The
spirit of MI, with its emphasis on compassion, collaboration, evocation,
and autonomy support, may be one way to bridge racial, cultural, or class
differences with clients (Rollnick, Kaplan, & Rutschman, 2016). All of
these attitudes and behaviors are consistent with cultural humility, which
is discussed in Chapter 10.
An MI interview can be helpful in learning about a specific culture. We
should not expect clients to teach us about or be a spokesperson for a cul-
ture, yet it is important to be open to learning from all of our clients. While
we need to find ways to learn about our clients’ cultures (NASW, 2015;
Sue et al., 2019), there is so much variability within racial/ethnic/cultural
groups that MI helps us to recognize what is important to a particular cli-
ent, and it may be different from our understanding of what to expect from
members of that culture. Thus we use MI to individualize care for clients in
the context of their view of and relationship to their culture(s).
How does MI get culturally adapted for specific groups of clients? As
funders and agencies are moving toward the integration of evidence-based
practices in client interventions, there is a need to take methods that have
been shown to be effective in tightly controlled clinical trials and apply
them to the real-life work of social workers in the community (Lee, Tava-
res, Popat-Jain, & Naab, 2014). It is also important to remain true to the
method and still adapt it for specific racial or ethnic groups, in order to best
meet their needs (Castro, Barrera, & Martinez, 2004). Making MI inter-
ventions appropriate for a particular culture can involve the use of focus
groups made up of clients or representatives from the culture. Discussions
of values and norms within a particular community as well as the use of
language can help shape an intervention while keeping it true to its original
design (Añez et al., 2008; Field, Oviedo Ramirez, Juarez, & Castro, 2019;
Interian et al., 2010; Oh & Lee, 2016; Venner et al., 2007). For instance,
an adaptation of MI for use with Native Americans (Venner, Feldstein,
& Tafoya, 2006) emphasized respect, no use of labeling, and collabora-
tion, all of which are congruent with Native American values and practices.
Focus group participants indicated that helping clients find their own moti-
vations and methods of change are extremely empowering (Venner et al.,
2007). Social workers Tsai and Seballos-Llena (2019) describe adapting MI
for Filipino clients through understanding how cultural values contextual-
ize MI concepts such as discord, motivation, and the roles of the family and
authority, among others.

MI Combines Well with Other Methods

Although MI can be used as a stand-alone intervention, it is also effective
when it is combined with other intervention methods, as either a pretreat-
16 INTRODUCTION

I have found that in working with my people, the Navajo People, some
types of communication methods or frameworks are ineffective. Sometimes
a framework requires a social worker to be leading the conversation in a
directive manner. Some will require long sessions of talk therapy. With my
Navajo clients these methods do not work. If I am directive, these clients
push back just as hard, or worse, they disengage completely. Navajos are
not talkers; we are usually a quiet and reserved people. That is where MI
comes in. MI has allowed me to start exactly where the client is, even if it is
in silence.
Navajo families are taught that it’s taboo to talk about death. I once
asked my grandparents about an uncle who had passed. I was scolded and
told that it was disrespectful to ask. In hospice social work, my job is to
talk about the impending death and to plan for the death. When I first
started asking assessment questions, I tried to question clients directly
about end-of-life topics. Of course, I am also Navajo, so clients were
offended that I didn’t respect the taboo. They would give professionals who
are not Native American a pass but definitely not me, someone who should
know better.
I still had to do my job, so I implemented MI. I enter clients’ homes
not as a social worker, but as relative. Navajo clients, who are usually older,
ask me what my clans are. This connects us right away, not as social worker
and client, but as relatives, as equals. In my work, I let the client direct all
communication. I am their companion in this hard time of pain, health
problems, and end-of-life decisions. And to my surprise, almost every time,
clients explain to me what they would like to leave behind or how they
would like their family to be when they are gone, thus planning the end-of-
life. Because I am their partner in their last chapter of life, they are open to
talking about what is traditionally taboo.
When I operate within the MI spirit, my clients are the teachers and I
am a mere social worker learning from my elders. I have learned so much
from my clients through this style of work. If I try to engage clients with any
other agenda, I will come up against a wall.

                  A ngel Tadytin, MSW

                  Hospice/medical social worker
                  Phoenix, Arizona

ment or a concurrent intervention, particularly with cognitive-behavioral

therapy (CBT) (Barrett, Begg, O’Halloran, & Kingsley, 2018; Gates, Sabi-
oni, Copeland, Le Foll, & Gowing, 2016; Lundahl & Burke, 2009; Marker
& Norton, 2019; Naar & Sufren, 2017; Peters et al., 2019; Randall &
McNeil, 2017; Westra & Aviram, 2015). Atkinson and Earnshaw (2020)
 Why Social Work and MI? 17

have recently written a book of MI-informed CBT, Motivational Cognitive

Behavioural Therapy. MI has been modified or adapted for various set-
tings. These adaptations include methods for conducting brief screening for
alcohol problems, as discussed below and in Chapter 7. MI also can be used
as one method to achieve goals within a larger intervention—for instance,
to engage parents in parent skills training or family group conferencing
meetings. Recently MI has been proposed for combining with interventions
based on positive psychology (Csillik, 2015).
Studies have found that an MI interview conducted before clients
enter treatment (such as for substance use, for mental health disorders,
or for intimate violence perpetrators) will increase program attendance,
engagement, and/or outcomes (Carroll, Libby, Sheehan, & Hyland, 2001;
Carroll et al., 2006; McCabe et al., 2019; Musser & Murphy, 2009;
Musser, Semiatin, Taft, & Murphy, 2008; Westra, Constantino, & Ant-
ony, 2016; Zuckoff, Swartz, & Grote, 2015). In these pretreatment MI
interviews, clients are asked to discuss what their concerns are and what
they would like to get from treatment. Providing the opportunity for cli-
ents to tell their story and to set treatment goals allows clients to engage
with the social worker or agency. Typically when these pretreatment inter-
views are studied, the interviewed subjects are compared to clients who
enter treatment without such an interview, but have a standard intake and
evaluation. Standard intakes include gathering of information from clients
such as their substance use history and current concerns, often done with
a battery of paperwork and forms. Intake interviews can be a subset of
the usual communication methods, whereby the state, agency, or social
worker deems what is important to know and the interviewer asks a lot
questions to get that information. Interestingly, in a systematic review, MI
was found to be effective especially in motivating clients who previously
were not seeking mental health services to pursue them (Lawrence, Ful-
brook, Somerset, & Schulz, 2017).
Corcoran (2005), a social worker, proposed the strengths and skills
model whereby MI was combined with CBT and solution-focused therapy
(SFT) for a variety of client problems. In this model, the social worker
uses MI and SFT to engage clients and learn of their concerns and moti-
vators; as ambivalence is reduced, the social worker switches over to the
discussion of the clients’ strategies for change with role plays, which is
consistent with CBT work. While there are few studies of MI combined
with SFT, Viner and associates (2003) found that adolescents with Type
I diabetes who received MI along with SFT and CBT were more likely to
have improved hemoglobin blood levels as compared to the control group.
Recently, Kaufman, Douaihy, and Goldstein (2019) also proposed strate-
gies to combine MI with dialectical behavior therapy (DBT), however it has
not been researched to date.
18 INTRODUCTION

Screening, brief intervention, and referral to treatment (SBIRT), which

utilizes MI skills, is receiving a lot of attention in social work education
(Cochran & Field, 2013). Typically SBIRT interviews take place in primary
care or an emergency department of a hospital, or more recently college
health centers (Hohman, Kleinpeter, & Strohauer, 2018; Naegle, Himmel,
& Ellis, 2013) and use MI within a structured format. With permission,
patients are screened, usually about alcohol use, are provided feedback
about the severity of their score compared with national norms, and are
asked to consider ways to cut back alcohol use in a supportive and col-
laborative manner. This takes about 15–30 minutes and studies of this
intervention have consistently demonstrated reductions in alcohol misuse
at 6-month follow-up (Bernstein et al., 2007; Madras et al., 2009). SBIRT
interviews also can focus on depression, tobacco use, or intimate partner
violence (Gilbert et al., 2015; Substance Abuse and Mental Health Services
Administration [SAMHSA], 2011). The MI skills used include asking per-
mission, open questions, reflective listening, affirmations, envisioning the
future, and planning (Hohman et al., 2018). See Chapter 7 for more discus-
sion of SBIRT.
Other brief interventions can take place over a few sessions, such as
the work done by John Baer and colleagues with homeless youth in Seattle.
Using MI, youth were screened regarding substance use and provided with
feedback on topics of their own choosing, such as substance use norms,
symptoms of substance dependence, motivation to change, and/or personal
goals. This was done over four short sessions in an attempt to reduce client
drug use and increase utilization of social services. Those who received the
intervention, as compared to a control group, increased their use of ser-
vices, but substance use declined for both groups over time (Baer, Garrett,
Beadnell, Wells, & Peterson, 2007).
MI is also used to obtain a goal within a different intervention, such as
parent skills training. Parent skills training typically uses CBT as parents
are taught a method and are given “homework,” in that they are asked to
practice the method at home with their children. Scott and Dadds (2009)
suggest the use of MI for parents who are either reluctant to engage in
the course or who do not follow through on assignments for a variety of
reasons. Sometimes we can actually increase discord in parents by argu-
ing with them about why they need to attend or by persuading or coaxing
them to cooperate. This can be done with the best of intentions as we may
be worried about the outcome if the parents don’t cooperate, particularly if
they have been mandated to take the class. Using MI helps us to listen to the
parents’ viewpoints and concerns in a nonjudgmental manner, thus reduc-
ing discord and, it’s hoped, increasing clients’ motivation to participate in
the intervention (Arkowitz, Westra, Miller, & Rollnick, 2008; Rollnick et
al., 2016; Mirick, 2012; Rosengren, 2018).
 Why Social Work and MI? 19

MI May Be Helpful in Reducing Burnout

Helping others who are suffering, whether physically, emotionally, or due
to social conditions, can be difficult and stressful. Social workers, as well as
health care professionals, first responders, probation officers, corrections
officers, and even journalists can be exposed to others’ trauma on a regu-
lar basis, which may cause what is called secondary trauma (Buchanan &
Keats, 2011). Burnout is closely related but tends to stem more from the
demands of one’s work. Burnout is defined as “the experience of physical,
emotional, and mental exhaustion that can arise from long-term involve-
ment in situations that are emotionally demanding” (McFadden, Campbell,
& Taylor, 2015, p. 1547). A systematic review of burnout and resilience in
child welfare studies found that burnout can be caused by personal factors
(exposure to secondary trauma, one’s own history of maltreatment, and
coping styles, among others) and organizational factors (workload, orga-
nizational culture, or lack of available and supportive supervision or peer
support) (McFadden et al., 2015). Burnout is a concern in social work and
child welfare in particular, as well as in the other above-listed professions,
as it impacts worker performance and retention.
Because there are so many factors that can cause burnout, it may seem
that the use of MI could make little difference. While there are few stud-
ies on the relationship between MI skills and burnout, the topic comes
up frequently in my community-based trainings for MI through anecdotal
stories. People report that after learning MI, they now enjoy going to work
and look for challenges of how they might use it in interactions with clients.
Miller and Rollnick (2013) even issue a challenge of sorts about approach-
ing an interaction with a client who is reluctant to change or argumentative
as an opportunity:

The client is probably rehearsing a script that has been played out many
times before. There is an expected role for you to play—one that has been
acted out by others in the past. . . . But you can rewrite your own role.
Your part in the play need not be the dry, predictable lines that the client
is expecting. In a way, MI is like improvisational theater. No two sessions
run exactly the same way. If one actor changes roles, the plot heads off in
a new direction. (pp. 210–211)

Other stories I have heard focus on the positive response that trainees
(social workers and others) receive from clients when they use MI skills,
which in turn causes trainees to use them more, as well as feel more effec-
tive in their work. Seeing these patterns, others have proposed learning MI
skills as a way to give practitioners—or in one case, Catholic priests—tools
20 INTRODUCTION

to be and feel more effective (McDevitt, 2010). Let’s take a look at the
research on this topic, which tends to be from the health care field.
Having good communication skills in general, higher empathy skills, and
an ability to take others’ perspectives have been found to be related to less
stress among physicians and social workers (Lusilla-Palacios & Castellano-
Tejedor, 2015). Damiani-Taraba and colleagues (2017) found that child wel-
fare caseworker engagement was related to client engagement in what they
believe was a reciprocal process. Pollak and colleagues (2016) trained physi-
cians and staff (roles not specified) from primary care and pediatric obesity-
focused clinics regarding MI. Subsequently, the trainers shadowed the staff
and physicians, giving immediate feedback and coaching on their MI skills.
When compared to control clinics who received no MI training, not only
did the patients in the MI-trained group indicate higher satisfaction with
their health care provider, the staff/physicians themselves indicated they felt
more effective in their interactions and reported lower burnout, as measured
by depersonalization questions. What might have made this difference? A
qualitative study of diabetes management nurses’ training in MI found they
felt a reduced burden of having to change or educate patients by giving more
of the responsibility or ownership for change back to the patients (Graves,
Garrett, Amiel, Ismail, & Winkley, 2016). Another study of MI-trained
nurses found they felt more empowered by seeing their patients become
empowered as they were able to motivate them to talk about the changes
that they (the patients) wanted. The nurses also felt they increased their own
empathy skills and were able to connect with patients on a more effective
level (Östlund, Wadensten, Kristofferzon, & Häggström, 2015).
MI may impact stress and burnout on the job through providing effec-
tive communication skills, but also through removing the need to change
or fix the clients who are in our offices or whose homes we sit in. Giv-
ing clients power, respect, autonomy, and choice provides them a different
way to interact with helping professionals, one that engages them—and
engages us further to remember why we went into the field of social work.
Of course, administrative or agency support of the use of MI is important
in its implementation, which is examined in Chapter 9. Finally, perhaps
the best answer of all the reasons that MI impacts burnout is this: Miller
(2019) recently noted that MI is enjoyable to practice!

What Are the Limitations in the Use of MI?

Currently MI has been applied to clients mostly in the micro (individual)

and mezzo (family and group) systems. Besides individual work, there are
applications of MI with couples (i.e., Starks et al., 2018), families (i.e.,
Draxten, Flattum, & Fulkerson, 2016; Gill, Hyde, Shaw, Dishion, & Wil-
 Why Social Work and MI? 21

son, 2008; Huang et al., 2015; O’Kane et al., 2019; Rollnick et al., 2016;
Sibley et al., 2016) and in group settings (i.e., D’Amico et al., 2015; Santa
Ana, Wulfert, & Nietert, 2007; Wagner & Ingersoll, 2013). An early study
by Miller, Toscova, Miller, and Sanchez (2000) included micro, mezzo, and
macro levels of intervention on a university campus for alcohol use with a
control comparison campus. Results found that drinking went up on the
control campus and remained flat at the intervention campus at posttesting
(fall to spring semesters).
In terms of the use of MI in macro settings, there is less research, but
Austin, Anthony, Knee, and Mathias (2016) discuss how micro skills, spe-
cifically MI, can be used in macro social work with community members.
MI has been applied in the development of community level/schoolwide
interventions (Komro et al., 2015) and has been proposed for use in work
with communities such as in forums regarding future planning (Costanza
et al., 2017). It has been used in more nontraditional social work settings
such as organizational energy reduction (Klonek & Kauffield, 2015), reduc-
tion of environmental waste (Klonek, Guntner, Lehmann-Willenbrock, &
Kauffeld, 2015), and farmers’ market and food pantry use (Freedman et
al., 2019; Martin, Wu, Wolff, Colantonio, & Grady, 2013). See Chapter
11 for a discussion on MI in environmental social work. MI has been pro-
posed as well as tested as an intervention to manage organizational change
and was found to be effective in assisting employees and holds promise
for those in leadership roles (Aarons, Ehrhart, Moullin, Torres, & Green,
2017; Grimolizzi-Jensen, 2018; Marshall & Nielsen, 2020; Stanhope et al.,
2016; Gunter, Endrejat, & Kauffeld, 2019).
One concern that has arisen is that MI methods do not utilize what
social workers would call the “person-in-environment” perspective (North-
ern, 1995) and that using MI takes the focus off of the multiple systems/
contexts that clients interact with day in and day out (Stanton, 2010). For
example, juvenile correctional workers who have participated in MI train-
ing have told me that it is one thing to interact with a youthful offender in
a manner that helps him or her move toward positive direction. But what
if the youth comes from a high-crime area, is illiterate, and has peers who
use drugs? How does having motivational conversations help the youth
when he or she has to confront all of these other mezzo and macro prob-
lems? Even using MI methods to help the youth strategize ways to address
barriers to, say, school attendance may not be enough to overcome the
myriad of problems inner-city youth face. A study of adults on probation
in Finland bore this out: while finding the probationers were motivated to
change alcohol use, social contexts (peers or family members who were
drug users, a cultural norm toward weekend drinking, and unemployment,
for instance) played a role in their choosing not to change alcohol and other
drug use (Sarpavaara, 2017).
22 INTRODUCTION

In a similar vein, I have heard social workers who work in the field
of interpersonal violence express concern that MI is just an individual
method and say they do not like having the focus on the survivor, instead
of on the culture of violence that is perpetuated through our media, music,
and cultural norms. Lauri (2019) and Egizio and colleagues (2019) discuss
this criticism at length. While MI is humanistic, empowering, and client-
centered, they argue that MI places too much responsibility on the client
for being the sole agent of change, which can renounce the responsibil-
ity of the therapist/social worker, society, and men’s own responsibility
for violence. There is no focus on collective action in MI. Going further,
Lauri (2019) is concerned that clients who can’t make the changes that are
expected of them at the individual level (becoming empowered, avoiding
violence, etc.) may be at risk for blaming themselves for failure instead of
recognizing systemic violence and the impacts of the larger macro environ-
ment. However, a recent study that is based on critical race theory (CRT),
and is discussed in Chapter 10, used CRT to recognize structural racism,
and imbedded discussion of it in an MI intervention regarding HIV medi-
cation adherence in African American and Latino males living with HIV
(Freeman et al., 2017; Gwadz et al., 2017). While using a many-pronged
approach in this study, results indicated increased medication adherence
and reduced viral loads in the participants (Gwadz et al., 2017).
Miller (2013) addressed Stanton’s (2010) concern that MI only focused
on the individual. He acknowledged that personal choice is only one aspect
of change, and of course there are larger contextual factors that also influ-
ence it. In looking at how MI fits in with social justice, Miller (2013) believes
those who are attracted to this humanistic communication model usually
have concurrent humane values that they operate under: compassion, respect
for all persons, justice, belief in human potential, acceptance, and collabora-
tion. Many who practice MI live out these values in various ways outside of
the therapy/counseling room, whether it is in volunteer work or advocacy,
or they use their MI skills in macro social work roles. Segal (2011), a social
worker, calls this social empathy, whereby empathy for individuals can lead
to helping to shape social policy, for instance. She believes there is an action
aspect to empathy, which is similar to what Miller is proposing.
Another limitation of MI for social work practice may be in the area
of learning MI. MI client-centered skills seem basic to some, but MI can be
difficult to learn as it is hard to overcome usual methods of communication.
MI has been described as “simple but not easy” (Miller & Rollnick, 2013).
Fortunately training studies have found that a variety of professionals—and
nonprofessionals—can learn MI to fidelity standards (Miller & Moyers,
2017). Research indicates that ongoing supervision, coaching, and feed-
back of skills are important (Miller & Moyers, 2017; Miller, Yahne, Moy-
ers, Martinez, & Pirritano, 2004). It took me quite a while before I felt my
MI skills were good enough to demonstrate an MI interview in front of an
 Why Social Work and MI? 23

audience. Receiving feedback and coaching on your MI skills take time and
often are hard to fit into already busy schedules (Barwick, Bennett, John-
son, McGowan, & Moore, 2012; Forrester et al., 2008; Miller & Mount,
2001). Recent innovative technology-based methods, including voice recog-
nition software that can code MI conversations and give immediate feed-
back, may help with this (Imel et al., 2019; Vasoya et al., 2019). A skillful
MI interview, as noted above, may not be enough to impact clients who
have multiple concerns (Forrester et al., 2018; Walters, Vadar, Nguyen,
Harris, & Eells, 2010), or perhaps agency policy and/or practices are not
supportive of the spirit and use of MI (Wahab, 2005a), which again makes
learning and practicing MI more of a challenge. Often, though, those who
are interested in increasing their MI skills find ways to do so despite time
and other constraints (see Chapter 9 for examples).

Final Thoughts

MI is an evidence-based practice, a communication style based on relational

and technical skills that emphasize collaboration, compassion, evocation,
and support of client autonomy. It fits well with the values of social work and
has been widely researched. Despite dissemination into social work research
and practice, MI may conflict with current practice, perhaps even more so
in settings where clients are involuntary and there is an investment in the
outcome. Despite its appeal, it can be challenging to learn, particularly when
we are overwhelmed with the demands of our work, or work in an agency
that does not support a client-centered approach (Miller et al., 2004). Usual
methods of communication include asking a lot of questions, perhaps label-
ing the problem, and seeing ourselves as experts who need to help clients fix
their problems. Using MI in many ways means learning how to communicate
in a different way and in other ways draws on the current skills social work-
ers have. In the next chapter, we will look at where MI came from, examine
some of the social psychological theories that explain how it works, and pro-
vide the framework for MI practice suggested by Miller and Rollnick (2013).

EPAS Discussion Questions

EPAS 1: Demonstrate Ethical and Professional Behavior

 Use reflection and self-regulation to manage personal values and maintain
professionalism in practice situations.

EPAS 4: Engage in Practice-Informed Research and Research-Informed Practice

 Use and translate research evidence to inform practice, policy, and service
delivery.
24 INTRODUCTION

1. Based on this introduction to MI, what aspects of the spirit of MI

may help or inform how to manage personal values and maintain
professionalism in social work practice?

2. Given the breadth of research of the use of MI, how has MI been
studied in your area of practice or internship? How has it been
implemented and what were the outcomes?
3. Is MI being used in your agency or internship site? If so, what
MI-congruent behaviors do you observe in your supervisor and
your colleagues? How does MI inform service delivery and policy,
if at all?
 C hapte r 2

The “How” of
Motivational Interviewing

EPAS 6-7-8: Engage, Assess, and Intervene with Individuals, Families,

Groups, Organizations, and Communities
 Apply knowledge of human behavior and the social environment,
person-in-environment, and other multidisciplinary theoretical
frameworks to engage/assess/intervene with clients and
constituencies. (CSWE, 2015, p. 9)

In the first chapter I defined MI, reviewed a bit of the extensive research
on MI, and discussed how MI fits well with social work values, ethics, and
practice. I also described the two components of MI: relational (spirit) and
the technical skills. But where did MI come from? How does MI work in
terms of theoretical explanations? And what is the best way to conduct an
MI interview? As I answer these questions, I hope you will have a better
understanding of what MI is all about. While MI is explored in more detail
in subsequent chapters, this chapter reviews how the spirit, skills, and four
processes (described below) are applied to various social work populations,
and discusses how context may shape how MI is used.

How Was MI Developed?

I love a good story, and how MI was developed is pretty interesting. Typi-
cally, new interventions or methods are designed based on utilization of a

25
26 INTRODUCTION

theory and generated hypotheses that are then tested, called the hypothetico-
deduction method (Coccia, 2018; Miller & Rose, 2009). This was not the
case in MI. Instead, an inductive method was used, based on clinical
observations (Miller & Moyers, 2017). William Miller, the creator of MI,
describes his work in the 1970s:

I got interested in this field on an internship in Milwaukee. The psychologist-

director . . . enticed me to work on the alcoholism unit, even though (and
because) I had learned nothing about alcoholism. Knowing nothing, I did
what came naturally to me, Carl Rogers, and in essence asked patients to
teach me about alcoholism and tell me about themselves: how they got
to where they were, what they planned to do, etc. I mostly listened with
accurate empathy. There was an immediate chemistry—I loved talking
to them, and they seemed to enjoy talking to me. Then I began reading
about the alleged nature of alcoholics as lying, conniving, defensive, slip-
pery, and incapable of seeing reality. “Gee, these aren’t the same patients
I’ve been talking to,” I thought. The experience of listening empathically
to alcoholics stayed with me and became the basis for motivational inter-
viewing. (in Ashton, 2005, p. 26)

Alcohol misuse treatment at that time (and to some degree, even today)
was based on the thinking that those with alcohol use disorders were in
denial about the seriousness of their drinking and its related problems.
In order to break through this denial and to see reality, counselors were
encouraged to confront clients about their denial, lying, manipulation, and
so on. Once clients had taken the first step of admitting to a problem, and
shown motivation to change, then they could begin the recovery process.
Counselors were the authority on how to recover (White & Miller, 2007).
Clearly Miller’s work was at odds with the practice standards at that time
and he became more curious as to what, from his experience, seemed to
impact clients.
Working at the University of New Mexico, Miller led experimental
studies testing behavioral interventions. Several studies included an assess-
ment with brief advice and assignment to a waiting list compared to the
same assessment with 10 sessions of cognitive-behavioral individual coun-
seling for clients with problem drinking concerns. The results indicated
that both groups did equally as well. Analysis of counselor style used within
the assessment found that the clients whose therapists displayed accurate
empathy had much better outcomes, even 1 and 2 years later (Miller, Tay-
lor, & West, 1980). Miller was also amazed to see that people who were
assigned to a self-help control group began to change their own drinking
based on just a brief intervention (Miller, 1996; Miller & Moyers, 2017).
Soon after his initial work and resulting research findings, Miller went
 The “How” of MI 27

on a sabbatical to Norway, and while there met regularly with a training

group of psychologists treating people with alcohol use disorders. During
role plays where he demonstrated his counseling methods, the psycholo-
gists would stop him and ask him to specify why he chose certain skills
and the decision rules for how he responded to what the client had to say.
This forced Miller to think about what had been an unconscious process
for him, and he wrote the first conceptual model of MI (Miller, 1983). This
model included client-centered work of empathic listening and strategic use
of questions and reflections. Miller wrote, “There is a lovely resonance in
the fact that MI was literally evoked from me” (Miller & Rollnick, 2013,
p. 373).
Miller extended this work. People with problem drinking (not labeled
as alcoholics) were recruited to participate in a study called the Drinker’s
Check-up. Using normative standards of drinking and related physical test-
ing, clients were given feedback regarding where they fell on these various
measures. Some were given this information in a client-centered empathic
style; others were given the information through a confrontational
approach, with the counselors telling the clients that they were alcohol-
ics. The group that received the confrontation style responded with double
the amount of sustain-talk statements (statements supporting their behav-
ior) and only half as much change talk (statements regarding change) as
compared to the group that received the empathic counseling style (Miller,
Benefield, & Tonigan, 1993).
In 1989, Miller met Stephen Rollnick, a psychologist from Wales, who
told him he had been using MI in his work in health care and that it had
become very popular in the United Kingdom. Rollnick asked to see more
written about it (Miller & Rollnick, 2013). This led to their collaboration
on the first book on MI (Miller & Rollnick, 1991), where they provided a
more in-depth look at MI, with a focus on addictions treatment. Rollnick
also expanded the concept and importance of ambivalence. A second edi-
tion of the book was published in 2002 with a more general focus, beyond
addictions work, and a third edition was published in 2013. The updated
content, based on research as well as practice, is presented in that third
edition.
As more practitioners and researchers learned about MI, the demand
for training in MI increased significantly. In response to the need for profi-
cient trainers, Miller and Rollnick created a process to train trainers, which
was the beginning of the MI Network of Trainers, or MINT (Miller &
Rollnick, 2013; Moyers, 2004). Over 3,000 professionals (social workers,
physicians, psychologists, probation officers, nurses, public health work-
ers, addiction counselors, and the like) have completed training for train-
ers since 1995, thus expanding the potential for learning MI. It is esti-
mated that over 15 million people internationally have been exposed to MI
28 INTRODUCTION

(Miller & Moyers, 2017). See Chapters 9 and 12 for information regarding
training and implementation of MI.

What Makes MI Work?

Most of us learned in college or graduate school that theories should be

used as the basis for any development of an intervention strategy. Social
workers need to be able to explain why something should work based on
logical hypotheses. The development of MI took a slightly different path,
as mentioned earlier. William Miller, though trained as a behavioral psy-
chologist, used the work of Carl Rogers to inform his interactions with
clients with alcohol problems. However, he based his methods on what
he saw was working—responding to various types of clients’ speech in an
empathic manner. He developed MI from mostly an atheoretical position,
so he began to explore what some of the theoretical bases might be to
what he was already practicing (Miller & Rose, 2009). Others have drawn
links to other social psychology theories that seem to explain what makes
MI work (Britton et al., 2008; Leffingwell, Neumann, Babitzke, Leedy,
& Walters, 2007; Markland, Ryan, Tobin, & Rollnick, 2005; Moyers &
Rollnick, 2002; Vansteenkiste & Sheldon, 2006) or have integrated theory
into research of MI (Boutin-Foster et al., 2013; Britton et al., 2011; Ehret,
LaBrie, Santerre, & Sherman, 2015). The inductive method of developing
and modifying MI has been critiqued (Atkinson & Woods, 2017), however
Miller and Rollnick (2013) find this a strength in that MI is able to respond
to the “real world of clinical practice” such as how to respond to clients
who do not see a need to change a particular behavior and engage them in
treatment services.
Based on these studies, I added material into my MI training and class-
room work about these theories that are based on social psychology. Other
than Rogers’s client-centered theory, social workers typically do not study
these theories (Payne, 2016). Even though students’ eyes tend to glaze over
at the mere mention of the word theory, I have found that understanding
these theories has made MI come alive for me and has impacted how I teach
it. Understanding why MI works the way it does provides the foundation
for the skills we utilize (Moyers, 2004). See Table 2.1 for an overview. Let’s
take a look at these theories.

Client-Centered Theory
Miller had been well trained in client-centered theory and counseling and
utilized methods including accurate empathy as proposed by Carl Rogers
when he worked with clients with alcohol use disorders, as noted above.
TABLE 2.1. Theories Used in MI and Some MI Practice Implications
Theory Author(s) Key points MI practice implications
Client- Rogers Humanistic; Belief in clients; listening as
centered (1965) humans strive healing; hopefulness and curiosity;
toward health; accurate empathy; evoke clients’
clients are experts own views, ideas, plans; see self as
on their lives; a collaborator/guide
importance of
relationship

Dissonance Festinger Behaviors that Explore goals, values, dreams;

(1957) conflict with discuss them in relation to behavior;
internal values acceptance, nonjudgmental to
cause discomfort; create safety for client
humans seek to
avoid discomfort
Self- Ryan & Humanistic; Respect autonomy; clients make
determination Deci (2002) humans have needs final choices; advice given only with
for autonomy, permission; assume clients have
competence, and knowledge and have ability to make
relatedness choices right for them; ask what
they already know about behavior
focus; affirm client strengths; focus
on the relationship
Self- Bem (1972) We learn about Avoid evoking sustain talk or shift
perception ourselves as focus when clients bring it up;
we observe our evoke change talk, hopefulness,
behaviors and hear confidence, abilities
ourselves talk
Self- Steele (1988) Humans need to Evoke abilities and past successes;
affirmation see themselves focus on core values; values
as competent exercises; appreciate clients’
(self-integrity); competence through affirmations
we are open to
messages that are
uncomfortable
if our worth is
acknowledged
Self-efficacy Bandura Appraisals of our Affirm prior successes and current
(1994, abilities to achieve small achievements; evoke hope
1999) tasks; confidence to from clients; ask clients to
change elaborate when you hear confidence
talk
Psychological Brehm & Humans react Pay attention to client discord and
reactance Brehm to preserve their utilize MI skills when it arises;
(1981) autonomy/freedoms discuss choices that are available
when threatened if clients are involuntary; avoid
arguing for change; pay attention to
social worker reactance

29
30 INTRODUCTION

Rogers’s client-centered theory was based on a humanistic model of human

nature. In brief, he believed that all humans strive toward health or positive
growth. Clients are seen as experts on their lives who understand best the
reasons and contexts for engaging in certain behaviors, even those that are
problematic (Rogers, 1957). Miller (1983) captured this notion in his early
description of MI when he said, “A motivational interviewing approach
treats the individual as a responsible adult, capable of making responsible
decisions and coming to the right solutions” (p. 155). It makes sense then,
that in MI we work in a collaborative fashion to evoke from clients their
perspectives, using reflections to gain and demonstrate understanding.
A fun exercise in training is to ask a participant to specify a needed
behavior change and talk about it a little (inevitably it is diet or physi-
cal activity, but I have been surprised on occasion, such as hearing, “I’m
a slob!”). The person is then asked to leave the room and the rest of the
trainees generate a list of ideas of what the person should do. The person
is brought back in and the trainer reviews the list—and almost always the
participant says, “No,” “Not that one,” “That one won’t work,” etc. This
brings home the point that what you might think of as good solutions usu-
ally won’t work for clients (or friends or family members). Ideas must come
from the clients.
MI social workers (and other practitioners) have “a quiet curiosity” in
their work with clients and focus on deeply listening (Miller & Rollnick,
2013, p. 32). Sometimes an MI interview is healing in itself as clients expe-
rience being listened to, without judgment or advice, perhaps for the first
time (Moyers, 2014). Rogers advocated being nondirective with clients and
held that practitioners should follow the lead of the client. MI is different
from Rogers’s theory/model in that there is usually a specific direction or
goal for behavioral change that the social worker or therapist works toward
(Miller & Moyers, 2017; Miller & Rose, 2009; Moyers, 2014) and you
can use your questions, reflections, and summaries strategically to work
in a particular direction. Although you support clients’ autonomy to make
decisions, even those you may not necessarily agree with, you still may
have a specific behavioral goal in your interviews with clients, often which
may be due to demands of the context such as court orders or the focus of
the agency. You want to monitor whatever aspirations you have for your
clients, however, and be transparent about them (Miller & Rollnick, 2013).
In your professional role, ask yourself from time to time about your
view of human nature (Miller & Rollnick, 2013). Most social workers are
attracted to the field for humanistic reasons, such as altruism: you want to
make a difference and are concerned about social justice (LeCroy, 2012).
You probably believe that given the right conditions, whether in the micro,
mezzo, or macro environments, people can make changes and overcome
obstacles. Sometimes this perspective can erode, owing to day-to-day work
that might include problems with supervisors, rules, regulations, lack of
 The “How” of MI 31

resources, or even problems with clients. As the idealism you may have had
when you left school with diploma in hand begins to wane, often it impacts
your perspectives on your clients and maybe even how you interact with
them. Signs of professional burnout or secondary trauma can include nega-
tive attitudes toward human nature: thinking clients can’t change, reducing
clients to labels, being sarcastic as clients are discussed, and so forth (Jud &
Bibus, 2018). Think about your own perspectives and your current views of
human nature. Can all humans change? Are all clients worth your respect,
hope, and valuing?

MI is a method that becomes second nature when you allow it. I have found
myself go from “doing MI” with clients to “being MI” in my role as an
adolescent therapist. From the moment clients walk through my door, they
are met with acceptance and empathy, no matter what the issue is or why
they are seeking treatment. It’s like a reflex: I tell them from the get-go that
this is a partnership. I am not here to judge, point fingers, or make them
change. I am sitting with them to be their partner in whatever healing or
change they want to take place. I find this approach especially effective with
teenagers with substance use disorders.
I can’t even begin to explain how ashamed—or angry—some of my
adolescent clients feel due to trauma from previous interactions that have
made them feel like failures. The language I use when interacting with clients
is intentional. I am mindful not to use any verbiage that could be shaming
or blaming, and I try to let them know they are not alone in what they are
experiencing. I’ve learned most clients really want to be heard. They want
to know their voice matters and that what they are saying is valuable. Many
clients I’ve worked with have told me I am the first person who has actually
listened to them. The amount of emotion and relief that washes over them,
especially when they finally understand I won’t judge them, is so powerful;
those moments really stay with me. I pull up those memories of clients when
I need a reminder of why I have pursued a career in social work.
It’s extremely gratifying to be able to meet clients where they are and
support them on making the changes they want to make, rather than telling
them what they need to do. I’ve seen a higher rate of successful treatment
completion when change is evoked from the clients themselves and they have
support to reach their chosen goals on their own terms. Some of the most
powerful work I’ve done in my 5+ years as a social worker has been through
using MI.

                   Jacqueline Fajardo, LCSW

                  Child/adolescent therapist
                  Davis, California
32 INTRODUCTION

Dissonance Theory
If humans are striving toward health, as indicated in client-centered theory,
then humans hold values at some level that are consistent with health or
growth. This might, depending on culture, include values such as want-
ing to be a good parent, be healthy, loved, admired, productive, and the
like. Often we engage in behaviors that are in conflict with these values
(e.g., smoking, gossiping, nagging our children, overeating). According to
Festinger (1957), people experience cognitive dissonance when they engage
in behaviors that are in conflict with personal attitudes. An example would
be someone who thinks health is important but still smokes. This conflict
produces anxiety or tension that can cause people to either (1) change the
behavior, (2) rationalize or justify the behavior, or (3) tell oneself that the
particular value is not that important. The smoker could quit smoking, tell
themself they only smoke six cigarettes a day which aren’t that much, or
think since they have other health issues, being healthy is not that impor-
tant to them. This theory was initially included in Miller’s first concep-
tion of MI (1983), and he proposed that the role of the practitioner was to
increase dissonance through empathic but strategic reflections, relating the
behavior to the value. The goal is to work toward changed behavior, rather
than changed attitude or values. All of this is to be done without shaming,
negative confronting, or reducing the client’s self-efficacy to change.
Often clients present without a spoken intent to change a behavior,
usually when they are under some sort of mandated order. Clients are
motivated—it just may not be in the direction that we want (Stinson &
Clark, 2017). Based on client-centered theory, however, you can assume
some parts of clients do want health and growth (physical health, mental
health, healthy relationships, etc.). An MI approach would be to first dis-
cuss topics not related to the behavior and learn about the client’s values,
goals, dreams, or aspirations. The social worker could then raise the behav-
ior using a goal, for instance, with modal verbs: “How might your smoking
impact your goal for your children to be healthy?” Miller and Rollnick
(2013) call this “instilling discrepancy” (p. 248), which is a slower, gentler
approach than any kind of confrontation or shaming. Another example
might be, “If you were to change your marijuana use, how might this affect
your goal of going to college?”

Self-Determination Theory
Self-determination theory is also based on a humanistic model (Vansteen-
kiste & Sheldon, 2006). In this theory, humans strive toward positive
growth and tend to do so in situations that support their autonomy, com-
petence, and relatedness to others (Ryan & Deci, 2002, 2017). These three
 The “How” of MI 33

needs are universal across cultures. According to the authors of this theory,
humans have intrinsic motivations, and when people are intrinsically moti-
vated, they choose to engage in activities because they find them enjoy-
able. People can also be extrinsically motivated. You might go to work
not so much for the enjoyment but for some other reward, such as income.
(We hope you have some enjoyment in it, too!) You can also be motivated
to participate in activities because you are pretty much forced to, such as
attending traffic school. For activities that require extrinsic motivation,
such as work, the more the setting supports your autonomy, competency,
and relatedness needs, the more likely you are to thrive in those settings
(Gagne & Deci, 2005).
What are the practice implications of this? Particularly in settings
with mandated clients, those clients who can have their autonomy, compe-
tency, and relatedness needs met, as much as possible, will be more likely
to engage in the services that are provided (Deci & Ryan, 2017). In MI you
support autonomy by asking clients for their perceptions and solutions and
by affirming that they ultimately are the ones who must make decisions and
choices. When clients ask for suggestions, they are given a menu of options
(Miller & Rollnick, 2013). You also can ask for permission before asking
a question. You support competence by working with clients to come up
with their own solutions or by asking permission before you give advice or
information. Relatedness comes from the use of reflections and summaries
that are given in an empathic manner and the collaborative nature of your
interactions with clients (Markland et al., 2005; Moyers, 2014; Teixeira et
al., 2020).

Self-Perception Theory
According to self-perception theory, people perceive themselves as they
articulate their thoughts in social interactions (Bem, 1972). Thus, how
clients talk about problems can be very important. If clients use a lot of
sustain talk, then they may be more likely to perceive themselves as unable
or unwilling to change because they become more closely identified with
or committed to the behavior. If clients engage in change talk, then they
may begin to think of themselves in a different way. Through your empa-
thetic reflections, with the use of summaries and questions where clients
are asked to elaborate, clients can hear themselves and develop a different
perspective on their situation (Cain, 2007; Rosengren, 2018).
What are the implications of self-perception theory? One is the old
adage: What you fish for is what you are going to get. If you ask clients
why they don’t want to or feel like they can’t change a particular behavior,
then you will get a lot of sustain talk: “It’s too hard,” “I tried before and it
didn’t work,” “I know I should give up now,” “I am always going to be this
34 INTRODUCTION

way,” and the like. As clients hear themselves, they will be more likely to
perceive themselves as unable or unwilling. Using self-determination theory
as an explanation, if you argue for change (and violate clients’ autonomy or
sense of competence), you will get the counterargument against what you
are arguing, causing clients to hear themselves and dig deeper into their
positions. This is also related to reactance theory, described below. While it
is important to hear some sustain talk when you are learning about clients’
views, in MI you work to direct the conversation away from it to encourag-
ing and evoking change talk. Recently at a workshop I led, a social worker
who participated in an MI learning exercise that involved discussing her
own reasons for change, stated, “I came up with reasons [for change] that
I didn’t even know I had! Having to say them out loud really made me
think!” She learned about herself as she heard herself talk.

Self-Affirmation Theory
Self-affirmation theory states that people need to perceive themselves as
competent in order to protect their self-worth, or literally, their self (Steele,
1988). If self-worth is kept intact, people are better able to hear messages
that are uncomfortable, a finding which is well supported by research
(Ehret et al., 2015; Reed & Aspinwall, 1998). When clients feel their self-
worth is under attack, they may react by arguing, defending, or withdraw-
ing. Thus, an important aspect of MI is to avoid labeling a client (e.g., drug
addict, drunk driver, bipolar, borderline, neglectful mother) for this threat-
ens the self-worth, is stigmatizing, and can cause clients to react negatively.
Affirming clients’ strengths, characteristics, and capabilities demonstrates
that you recognize them (and their self) and may help clients become more
open to discussing areas of concern. Even stronger are self-affirmations.
Cohen and Sherman (2014) define self-affirmations as “an act that dem-
onstrates one’s adequacy” (p. 337). These are affirmations that the social
worker evokes from clients so that (in line with self-perception theory) cli-
ents themselves do the talking about what they see as their strengths, posi-
tive behaviors, what is important to them, and what makes them unique.
For instance, at the beginning of each semester, I ask students to write
about themselves so that I can get to know them better. One of the ques-
tions I ask them is, “Tell me about a time when you were successful at
something.” I get to read some fun replies—like about learning how to
salsa dance, getting a promotion, taking on a new task at work, partici-
pating in a triathlon. My point with this assignment is to get to know stu-
dents better outside of the classroom but also for them to hear themselves
describe themselves as successful. I also use a follow-up question, “What
will you do to be successful in this class?” In a clinical situation, the social
worker might ask the same past success question and then ask, “What
 The “How” of MI 35

did you learn about yourself when you were successful?” and then, “How
might what you learned about yourself in that situation help you with this
one?” Ehret and colleagues (2015) propose integrating a self-affirmation
exercise into an MI session, such as asking clients to select a value from
a list of positive values and write briefly about it. What they write is then
discussed with the social worker. The idea is to discuss clients’ values of,
say, family, and how they live in ways that are consistent with that value.
At this point the exercise is not connected to the target behavior or focus of
the interview, but as a way to let clients know the social worker sees them
as a whole human being, not just the problem. This, in turn, may promote
openness to discussion of the target behavior. (See Chapter 4, on focusing.)

Self-Efficacy Theory
In a similar vein, self-efficacy theory is related to people’s perceptions or
appraisals of their ability to engage in or perform a particular behavior
(Bandura, 1994, 1999). People with high self-efficacy have strong beliefs
that they are able to accomplish challenging goals. Those with low self-
efficacy tend to avoid tasks in which they fear they will fail in relation
to the particular goal. In MI, motivation to change has two aspects: the
importance of the change and the confidence to make the change (Miller
& Rollnick, 2013; Rollnick, Miller, & Butler, 2012). Clients may give high
importance to making a change such as quitting smoking and also feel
low in confidence to actually do it. According to Bandura (1994), efficacy
can be influenced in four ways, and they are listed in sequence accord-
ing to their strength in raising self-efficacy: (1) through accomplishment of
other, similar experiences; (2) through observing someone similar achieve
the change or task (modeling); (3) through persuasion by someone else that
change is possible, and (4) through reduction of stress or negative mood
state toward the change. Increasing self-efficacy has been linked to positive
outcomes. For instance, a 2013 study by Chariyeva and colleagues found
that focusing on enhancing self-efficacy (confidence) within MI interviews
increased safer sex practices among the study sample, who were people liv-
ing with HIV/AIDS.
How can you enhance self-efficacy? Miller and Rollnick (2013) note
that “finding hope is not a matter of creating it from nothing but rather of
calling forth that which is already there. Hoping is a truly collaborative
interpersonal process, and one in which it is a profound privilege to par-
ticipate” (p. 229). As in client-centered theory, you assume hope is already
available in clients, even if it isn’t apparent. Your job is to call it forth.
Affirmations can have a strong role in building confidence. Thus,
thinking about affirmations from an MI perspective (and the deficit vs.
competency perspective), the goal of the affirmation is not to let clients
36 INTRODUCTION

know what you think or value (e.g., “I think you are a devoted daughter”
or “It is good you chose to take care of your dad”). Instead, affirmations
let clients know you see what they already see in themselves (e.g., “You
worked hard to make sure everything was taken care of for your father”).
As noted above, you can ask clients what they see as their strengths or
positive attributes, and use reflective listening to reinforce what they hear
themselves saying (self-perception theory). If clients ask for advice on how
to change, you can describe what other clients have done in similar situa-
tions (modeling). In MI you try to avoid persuasion as this tends to elicit
sustain talk, but you can help reduce stress through helping clients pick
small, obtainable strategies when they are ready to change (Rosengren,
2018). You can also evoke confidence talk through the use of a change
ruler, described in Chapter 5.

Psychological Reactance Theory

According to Brehm and Brehm (1981), psychological reactance occurs
when people react to preserve their freedoms or autonomy. Thus, when
people think that their free will or choice is being threatened, they react by
becoming angry, state the opposite side of the argument, or choose to con-
tinue the behavior under discussion. Thus, a parent court-ordered to a par-
enting class may choose to attend in order to keep her children, but in the
classroom she is disruptive or uninvolved. This can be her way of asserting
her autonomy and according to reactance theory, is normal behavior when
someone is in a forced situation (Mirick, 2018; Mirick, Altman, & Goha-
gan, 2018). Reactance may come from being in an involuntary setting as a
client, where there may be power differentials between the social worker
and client, goal conflicts, rule-based services, pressure to change, along
with prior or current experiences with social workers who were negative,
racist, or demeaning, and the like (Mirick, 2012; Rooney & Blakey, 2018).
Linking reactance theory to self-determination theory, it is also likely that
clients (and others) react when they feel their autonomy, competence, or
relationships are threatened. What is significant about reactance theory is
that it explains that this kind of client behavior is a normal response that
can be predicted in such circumstances (Miller & Rollnick, 2013; Mirick,
2012; Mirick, 2018).
A second important aspect of reactance theory is what Rooney and
Blakey (2018) and Jud and Bibus (2018) describe as social worker reac-
tance. You, too, can respond in ways not compatible with MI (such as
arguing or being directive) when you have your competence questioned by
clients (Laws et al., 2015). Your work setting as well may diminish your
autonomy by implementing organizational changes you are told you have
to make. A judge may make unrealistic demands regarding your work with
 The “How” of MI 37

a particular client. Social workers, particularly those in child welfare work

who are under court timeline pressures, can fall into a cycle of arguing
for change or exerting power when clients do not comply, which in turn
produces more reactance in clients (Rooney & Blakey, 2018; Stinson &
Clark, 2017). As a professional social worker you are expected to manage
personal feelings and reactions; thus, understanding your own reactance is
a step in that direction.
Reactance in MI had been called resistance; however, it is now concep-
tualized as sustain talk (as mentioned above, clients defending of the status
quo, highlighting why they can’t change or why the behavior is important
to maintain) or discord (such as when clients attack the social worker as
incompetent, or not understanding, or make some other comment about
the relationship) (Miller & Rollnick, 2013). This terminology change was
based on research of MI conversations as well as the desire to not patholo-
gize clients by labeling them resistant. Reactance theory normalizes these
types of behaviors or statements in clients as predictable responses to a loss
of freedom (or autonomy or sense of competence, etc.). They stem from
interpersonal interactions in which you play a role.
How do you respond to client reactance? As noted above, view defen-
siveness, lack of compliance, or argumentation as normal behavior to be
expected, particularly when clients feel a loss of control or threatened or
have their competence questioned (Miller & Rollnick, 2013; Mirick, 2012).
This will help in managing social worker reactance as well. The MI spirit
of collaboration, respect, and autonomy support and skills of expressing
empathy, reflective listening, providing choices (even in limited circum-
stances), and asking permission before providing information will reduce
reactance, or in MI-terms, reduce client discord and increase client engage-
ment (Mirick, 2012). As noted earlier, when you hear sustain talk, you
want to acknowledge it through reflective listening, but move the conversa-
tion to change talk as soon as you can. I explore sustain talk and discord
and strategies to address them more in-depth in Chapter 6.

How Is an MI Interview Structured?

Often, experienced social workers who are taking an introductory work-

shop in MI tell me that they already know MI as they begin to hear about
it. Typically, what they mean is that they are familiar with client-centered
theory and techniques. Sometimes the social workers or therapists are
already using these methods in their practice. Clinicians and others who
work using this model tend to embrace the spirit of MI and are eager to
learn more about it. As Miller said, clinicians recognize it when they see it
and want to learn about it (Miller, 2013).
38 INTRODUCTION

Beyond implementing the spirit of MI, and keeping social psychologi-

cal theories in the back of our minds when communicating with clients,
what else is involved? As noted earlier, there are the technical skills such
as open questions, affirmations, and reflective listening, all of which are
discussed with examples in Chapter 3 and throughout the rest of this book.
The following is an overview of the structure of an MI interview, intro-
duced by Miller and Rollnick in 2013.

The Four Processes of MI

In social work education we teach the generalist intervention model (GIM):
engage, assess, plan, implement, evaluate, terminate, and follow up. The
GIM comprises these sequential steps that could be used across micro,
mezzo, and macro client systems (Kirst-Ashman & Hull, 2018). Based on
feedback from clinicians as well as their own experiences, Miller and Roll-
nick (2013) sought to establish a structure of how an MI interview can best
flow and provided what they call the four processes: Engaging, Focusing,
Evoking, and Planning. When I first heard them present these processes at a
MINT conference, I thought it sounded similar to the GIM that I had been
teaching in my general social work practice classes. But as they explained
them, I saw that there were also differences.
The first difference is the focus on processes and not phases or stages.
The GIM for the most part is a linear stage model. Miller and Rollnick
(2013) use a graphic of a staircase (Figure 2.1) to indicate that while there
are steps in the process, they are not necessarily linear, and the clinician
needs to traverse up and down them as needed. If, for example, during the
Evoking process you inadvertently cause discord, causing the client to dis-
engage from the relationship, then you need to walk back down the stairs
to Engaging. As noted in the next chapter, Engaging is a continual process.
Another difference from the GIM is that the four processes can be used as
a guideline for even a brief interview, such that an emergency department
social worker might conduct. Rollnick and colleagues (2016) describe rapid
engagement that can be used in brief interactions with students in school
settings. It is not always necessary to get to the top of the staircase, Plan-
ning, for an interview to be considered an MI interview; however, Engag-
ing, Focusing, and Evoking are always involved (Miller & Rollnick, 2013).
On a side note, while discussing stage/process models of intervention,
students and trainees sometimes ask why I don’t emphasize the transtheo-
retical model (TTM) or stages of change (Prochaska & DiClemente, 1984).
This was developed at the same time as MI, and while these models inform
each other and are complementary, they are not the same. Miller and Roll-
nick (2013) state, “MI is not meant to be a comprehensive theory of change,
and the popular TTM stages of change are not an essential part of MI”
 The “How” of MI 39

                           Planning

                    
Evoking

             Focusing

     Engaging

FIGURE 2.1. Four processes in MI.

(p. 35). MI is especially useful for those who are in any stage of the TTM,
whether it is thinking about a change, planning a change, or practicing the
new behavior.
While many of the following chapters delve into the four processes
more in depth, along with examples of social work practice, let’s take a
quick look at each of them. Engaging as a process is at the heart of social
work practice. Relationships with clients form the basis for your work. The
NASW Code of Ethics (2017) lists human relationships as a value along
with the ethical principle that social workers prioritize the relationship with
clients: “Social workers understand that relationships between and among
people are an important vehicle for change. Social workers engage people
as partners in the helping process. Social workers seek to strengthen rela-
tionships among people in a purposeful effort to promote, restore, main-
tain, and enhance the well-being of individuals, families, social groups,
organizations, and communities” (p. 6).
Engaging is key to establishing any kind of helping relationship or
working alliance. It does not happen only in counseling or therapeutic rela-
tionships. Social workers work in many roles and need to engage with cli-
ents in all settings (Eaton, Craig, & Wallace, 2017; Rollnick et al., 2016;
Stinson & Clark, 2017). Engaging clients is important as it is strongly
related to positive outcomes (Moyers & Miller, 2013).
In the Engaging process, clients are essentially wondering about their
social worker (or doctor or other helping professional), “Can I trust this
person?” Engaging involves social workers setting the tone using the MI
spirit of acceptance, collaboration, autonomy support, empathy, and evoca-
tion, and using MI skills including open-ended questions, reflective listen-
ing, affirmations, and summaries. You convey the spirit of MI as you get to
know clients, including their current concerns, or hopes, or values. The art
of MI is that there is no one direction to go in during the Engaging process.
The goals are to establish a trusting relationship as well as to learn enough
about the client to guide them to the next process of Focusing.
As stated earlier, sometimes social workers and other professionals
40 INTRODUCTION

believe MI is basically client-centered skills; however, its key is the recogni-

tion of the importance of guiding clients by evoking change talk (Miller &
Moyers, 2017). Change talk must have a target behavior or a focus. Focus-
ing is determining in collaboration with clients what the agenda or the
goals of the conversation will be. What are some typical change behaviors
that social work clients might identify? They could include getting one’s
children back, making changes in alcohol use, giving up a driver’s license,
taking needed medication, meeting requirements of getting a job, dealing
with depression symptoms, enrolling in a food assistance program, and so
on.
Once the goal has been established, social workers then begin Evok-
ing change talk from clients, asking about the why of change, reasons for
change, abilities to change, or the need to change, reflecting as they go
along. The goal is for clients to discuss their own motivations for change
and to hear themselves discuss them (self-perception theory). “People talk
themselves into changing” (Miller & Rollnick, 2013, p. 28). Reflections
and summaries are MI skills to provide empathy as well as to reinforce
what clients are stating (see Chapter 3 for more detail about reflections and
summaries). These skills help you to guide the conversation.
Sometimes clients see social workers when there is no clear direc-
tion for change: “Should I get a divorce?”; “Should I go back to school?”;
“Should I move back to my hometown?”; “Should I tell my children that I
am undocumented?” This is where both answers—yes or no—could have
positive or negative outcomes, and it is not up to social workers to guide
the client in a specific direction. In these situations you have neutrality or
equipoise, which means you have no specific goal or direction in mind
(Miller & Rollnick, 2013). MI spirit and skills can still be utilized but with
no need to focus on a direction. In these situations, you could explore vari-
ous outcomes of choices with clients with the intention of not influencing
them.
The last process is Planning. Clients may or may not choose to engage
in planning. Clients may describe why and how they may engage in a cer-
tain change and then get overwhelmed with a lack of confidence, feeling
that it is too much, and then back off. You would then return to Evoking,
to ask perhaps about other times when clients were successful. Or, clients
may state they are just not ready to make the commitment to planning steps
on how to change. Does this mean that the MI was not successful? Not at
all, as seeds for change have been planted.
Planning has been characterized as moving from the “why” to the
“how” (Resnicow, McMaster, & Rollnick, 2012). Clients who are ready to
engage in Planning utilize language that describes commitment (“I think
I am ready to do what it takes”). Social workers evoke from clients what
steps they think are appropriate. Their own ideas can be added in only after
 The “How” of MI 41

clients’ ideas have been exhausted, with permission to share some thoughts
on other choices (self-determination theory).

Final Thoughts

In Chapter 1, I provided a definition of MI and the aspects of the MI spirit:

partnership, acceptance (autonomy support, accurate empathy, and affir-
mation), evocation, and compassion (Miller & Rollnick, 2013). As indi-
cated in the history of MI, Miller took elements of Rogers’s client-centered
theory and work that included accurate empathic listening. Using these
methods, Miller worked in a collaborative fashion with alcohol treatment
clients and evoked from them their stories, including how they came to be
in the treatment center and what their goals were. In reflecting on his work
in Norway, he realized that he used questions and reflections to respond to
selective statements made by his clients, particularly statements regarding
change in the positive direction. This approach was somewhat different
from the nondirective nature of Rogers’s work (Miller & Rollnick, 2013).
Miller’s focus on these statements became the basis for what was termed
eliciting “self-motivating statements” (Miller, 1983; Miller & Rollnick,
1991) from clients, and later changed to evoking “change talk” (Miller &
Rollnick, 2002; Miller & Rose, 2009). How social workers and counsel-
ors recognize and address change talk, in many ways, is what makes MI
different from the work set forth by Rogers. While MI was initially used
in addictions treatment, it has been used and studied in a wide variety of
behaviors, as seen in Chapter 1.
Social psychological theories help to explain why MI works as it does,
as well as the practice-related behaviors that are used in MI. So to sum up,
in combining these theories, clients have a need for connection, compe-
tence, and autonomy (self-determination theory) and when this autonomy
or self-worth is threatened (reactance theory and self-affirmation theory),
clients tend to react in a way to preserve these things (sustain talk and/or
discord). They listen to themselves describe why they can’t or won’t change,
or they reduce the importance of the problem (self-perception theory, dis-
crepancy theory). Clients who feel engaged, valued, and connected to their
social worker (client-centered theory) are more likely to see themselves as
competent and capable (self-efficacy theory, self-perception theory) and
become more open to discussing reasons and need for change (change talk).
And research indicates that the more clients talk about change, the more
likely they are to embark on this change (Amrhein, Miller, Yahne, Paler, &
Fulcher, 2003; Apodaca & Longabaugh, 2009).
In the following chapters I examine more closely the four processes
and skills of MI, put them in contexts that are common to social workers,
42 INTRODUCTION

and provide sample interviews. Having an understanding of the history and

theories that support why MI works as well as it does will be helpful as you
learn and practice MI skills.

EPAS Discussion Questions

EPAS 6-7-8: Engage, Assess, and Intervene with Individuals, Families, Groups,
Organizations, and Communities
 Apply knowledge of human behavior and the social environment, person-
in-environment, and other multidisciplinary theoretical frameworks to
engage/assess/intervene with clients and constituencies.

1. In looking at the social psychological theories on Table 2.1, pick

one that strikes you as interesting. How might you apply it to your
work with clients now? What might you do differently?
2. How might you apply these theories beyond the micro setting?
What implications do they have for the mezzo and macro settings?
3. What do you do now to engage clients in your work or internship
setting?
 PA RT II
Elements of
Motivational Interviewing
 C hapte r 3

The Engaging Process

Building Trust

EPAS 1: Demonstrate Ethical and Professional Behavior

 Use reflection and self-regulation to manage personal values and
maintain professionalism in practice situations.
EPAS 2: Engage Diversity and Difference in Practice
 Present themselves as learners and engage clients and
constituencies as experts of their own experiences.
EPAS 6: Engage with Individuals, Families, Groups, Organizations, and
Communities
 Use empathy, reflection, and interpersonal skills to effectively
engage diverse clients and constituencies. (CSWE, 2015, pp. 7, 9)

As mentioned in Chapter 2, I was attending an MI trainers’ conference

when Bill Miller and Steve Rollnick (2013) presented their conceptualiza-
tion of the four processes—Engaging, Focusing, Evoking, and Planning.
While I found this to be a helpful structure, I knew engagement was some-
thing commonly described in social work textbooks and practice mod-
els, and was well incorporated in social work practice. I was happy to see
Engaging included in MI as an intentional step in the framework.
As I listened to their presentation of the four processes, however, I real-
ized they were describing something a bit different from what I had learned
and taught about engagement. They were describing Engaging as an ongo-

45
46 ELEMENTS OF MI

ing process used throughout an MI interaction, not a step such as presented

in the GIM (Kirst-Ashman & Hull, 2018) or in the Educational Policy and
Accreditation Standards (EPAS) specified by the CSWE (2015). The EPAS
lists the verb engage as separate from assess, intervene, and evaluate and
social work students are asked to demonstrate (through the EPAS) the abil-
ity to engage clients. How exactly is the Engaging process different from
the engagement step?
Consider how engagement is defined in social work practice. It is
seen as something skill-based/relational, a task-oriented step, or both.
A relationship with the client (individual, group, family, community,
organization) starts with the use of basic counseling skills. These include
nonverbal body language as well as verbal communication, with a focus
on demonstrating empathy, use of open-ended questions, and engender-
ing hope (O’Hare, 2015). Engagement as a step within a larger practice
framework may also contain tasks, such as enrolling a client in services,
making sure the client understands the types of services offered, deter-
mining if services are congruent with the client’s needs, and complet-
ing the required paperwork (Kirst-Ashman & Hull, 2018). A client can
be considered engaged if he or she returns for services or complies with
required homework assignments or court orders (Stinson & Clark, 2017).
Once the client is engaged, then typically the next step would be assess-
ment (Kirst-Ashman & Hull, 2018). Interestingly, CSWE (2015), while
delineating engagement as a separate step, also notes that engagement
is “an on-going component of the dynamic and interactive process of
social work practice, with and on behalf of, diverse individuals, families,
groups, and organizations” (p. 8).
This aspect of a dynamic and interactive process is closer to how Engag-
ing as a process is defined in MI. Miller and Rollnick (2013) write that
Engaging is “the process of establishing a mutually trusting and respectful
helping relationship” (p. 40). Engaging, as a process rather than a step, is
where clients begin to build—and maintain—a sense of trust in their social
worker as they are listened to, respected, and seen as individuals. Rosen-
gren (2018) calls the Engaging process the “relational foundation” (p. 51)
of the client–practitioner interaction. He notes how Miller and Rollnick’s
(2013) definition implies the social worker establishes trust in the client as
well. How you think about and approach your clients will influence how
well you are able to establish any kind of therapeutic alliance or relation-
ship with them. This takes us back to client-centered theory that states that
a part of each person wants to move toward change and positive growth.
If you believe this to be true, then you immediately trust that your clients
will want to do what is best for themselves. If you approach clients with
suspicion or negative expectations, then it becomes difficult to establish a
mutually trusting relationship.
 Engaging 47

In both engagement as a stage and Engaging as a process, there is a

focus on warmth, genuineness, respect, nonjudgmental dialogue, collabo-
ration, compassion, and partnership—in fact, aspects of the spirit of MI
described in Chapter 1. MI explicitly adds in autonomy support, which in
the language of self-determination theory, means clients are immediately
viewed and treated as the experts on their lives, and capable to make deci-
sions. In teaching many Latinx students over the years, I would also discuss
the use of cultural values/behaviors such as personalismo (a personalized
approach) and platicando (chatting to create a warm atmosphere) (Zuñiga,
1992). Approaching clients with the spirit of MI can help establish a work-
ing relationship. Beyond that, however, Engaging is a continual process in
that a social worker must always be aware and attuned to how clients are
responding, even when the social worker may have moved on to the other
processes of MI (Schumacher & Madson, 2015). How clients respond is
described in the metaphor by Miller and Rollnick (2013): Are you dancing
or wrestling with your client? If you are dancing with your clients, then you
know you are Engaging them. Typically, clients who are Engaged tend to be
more relaxed, more verbal, and self-disclosing—basically, you and the cli-
ent are involved in the conversation heading in a positive direction. Further
in this chapter I will look at what might inhibit engagement. Chapter 6 also
describes client disengagement or discord and what that might look like.

Demonstrating Empathy through Reflective Listening

So far I have described how a social worker approaches an MI interview by

Engaging clients, to create trusting relationships that continue through the
rest of the four processes. The counseling skills cited by many social work
textbooks are also used in MI, such as open-ended questions, affirmations,
reflections, and summaries, which in MI are also known by the acronym
OARS. Demonstrating empathy is also a key in Engaging.
MI was started, as we learned in Chapter 2, when Bill Miller, as an
intern, began to work with patients in alcoholism treatment and didn’t
know what he was supposed to do. Being a student of Carl Rogers, he
did know how to use reflective listening skills in a client-centered manner,
which was not typical of alcohol treatment at that time. Miller found that
his patients responded well and went on to be open in their discussion of
their problems and concerns. His research studies confirmed his experien-
tial finding: the alcohol treatment clients who reduced their drinking had
therapists who interacted with higher levels of empathy (Moyers, 2004).
Over the past half-century, Rogers’s work (1957) has continued to
influence therapists and social workers, with his emphasis on the core
conditions of empathy, unconditional positive regard (sometimes called
48 ELEMENTS OF MI

acceptance), and congruence (sometimes known as genuineness). Practi-

tioners are drawn to this humanistic approach, and decade after decade
of research has continued to support the impact of Rogers’s theory/model
(Kirschenbaum & Jourdan, 2005) and the importance of empathy and the
practitioner/social worker–client relationship. Empathic relationships are
related to successful outcomes, independent of the specific type of therapy
used (Moyers, 2014; Moyers & Miller, 2013).

Defining Empathy

What do I mean by empathy? One of the best sources for a definition is

Rogers’s own version. He stated that empathy is

to perceive the internal frame of reference of another with accuracy, and

with the emotional components and meanings which pertain thereto, as
if one were the other person, but without ever losing the “as if” condi-
tion. . . . [It is] to sense the hurt or the pleasure of another as he senses
it, and to perceive the causes thereof as he perceives them, but without
ever losing the recognition that is as if I were hurt or pleased, etc. (1959,
pp. 210–211)

Thus, empathy involves understanding the world or problem as the client

sees it without identifying with or taking on the problem.
Empathy is to be distinguished from sympathy, which is the expression
of concern or compassion for another’s problem or distress and can be a
roadblock to communication (Miller, 2017; Rosengren, 2018). Expressions
of sympathy can include “I am so sorry that this happened to you” or “You
poor thing, the world just seems to be falling apart for you.” Sometimes
when I teach or train MI, trainees confuse the two concepts and think
that by entering the world of another and listening to it, that this some-
how conveys acceptance or soft-heartedness (Stinson & Clark, 2017). As
one trainee, who was a probation officer, told a colleague, “I only have
empathy for the victim!” Empathy is understanding the concern or problem
from the client’s perspective. You accept your clients as humans, and being
empathic with them does not mean you accept or approve of certain behav-
iors (Miller & Rollnick, 2002, 2013).
Other definitions of empathy describe the relational or interactive
aspect in the expression empathy. Empathy is

the practitioner’s accurate perception of the internal frame of reference

of a client and communicating this understanding to the person. (Clark,
2010, p. 348)
 Engaging 49

the skillful and deliberate ability to convey a sense of being present, under-
standing the client’s words, emotions, and underlying meaning. (Feldstein
& Forcehimes, 2007, p. 738)

connecting with the other person [with] an active interest in what he or

she is experiencing. (Miller, 2018)

These definitions address how empathy involves not only understanding

what your clients are communicating but conveying this understanding
back to them. Barrett-Lennard (1981, p. 94) calls this the empathy cycle.
As shown in Figure 3.1, in this cycle, clients express their thoughts, ideas,
or feelings (Step 1). As a social worker, you listen and attempt to under-
stand the messages that clients are trying to convey, whether directly spo-
ken or unspoken (Step 2, empathic resonation). You then express empa-
thy by communicating statements that indicate an awareness of what your
clients are experiencing or thinking (Step 3, expressed empathy). Clients
then receive your empathy and (hopefully) feel a sense of being understood
and listened to (Step 4, received empathy), which causes them to continue
to communicate (Step 5, fresh expression and resonation), which is really
Step 1 all over again. Expressing empathy encourages clients to continue
to describe their concerns or thoughts. You learn what clients’ perspectives
are and in the process, they hear themselves think out loud, sometimes
hearing their own internal arguments for the first time. Being listened to in
a focused, nonjudgmental, accepting manner can be a new experience for
some and allows clients to feel valued as individuals and be more open to
discussion of uncomfortable topics (Myers, 2000; Rogers, 1957; Wagner &
Ingersoll, 2013).

The Empathy Cycle

Step 1: The Client Speaks
Using the empathy cycle (Barrett-Lennard, 1981) helps you to examine the
process of expressing empathy. If expression of empathy is done in a rela-
tional context, what are the necessary ingredients? As discussed in earlier
chapters, the spirit of MI provides the approach to your work with clients.
If you convey respect, curiosity, and interest, with a focus on listening as
well as a willingness to learn, you can set the groundwork for the start of
the empathy cycle (Miller, 2018). When you were a social work student,
you most likely learned about attending skills in your social work prac-
tice classes and became familiar with concepts of body language, appro-
priate eye contact, open posture, and so on (Hepworth, Rooney, Rooney,
& Strom-Gottfried, 2017). These are the main skills that are needed in
50 ELEMENTS OF MI

FIGURE 3.1. The empathy cycle (Barrett-Lennard, 1981).

Step 1, where the client speaks. You create an atmosphere where clients are
receiving all of your attention and feel your full focus. This can be espe-
cially difficult in interviewing clients in certain social work contexts, such
as in clients’ homes with TVs blasting or phones ringing (Kirst-Ashman
& Hull, 2018). Interviewing clients in prisons, residential treatment cen-
ters, or shared offices can also be distracting. Social workers are good at
working past these distractions. As clients feel your full focus, they become
more likely to communicate more personal or important messages (Moy-
ers, Miller, & Hendrickson, 2005). Using (a little) small talk and then a
general open-ended question are good ways to invite clients to speak.
Using open-ended questions is one of the MI skills in OARS. It can be
a start in the Engaging process by asking clients, perhaps, “Tell me a little
bit about yourself.” Sometimes clients want to avoid small talk and get
down to business right away, describing why they are seeing you as their
social worker. Asking our clients, “What is on your mind today?” or “How
would you like to use this time together?” allows them the opportunity to
set the agenda of what they would like to cover. Of course, you as the social
worker or probation officer, for instance, may also have items or topics
 Engaging 51

that you would like to cover and in working in a collaborative fashion, you
share with the client your agenda items as well (Stinson & Clark, 2017),
as discussed in the next chapter on Focusing. Also, assessment information
may need to be gathered, depending on the social work setting, but only
after the Engaging process has been undertaken.
Open-ended questions can be used throughout all of the four pro-
cesses and are questions that have a variety of possible answers and do not
limit the client. Closed-ended questions, such as “What is your address?,”
tend to be those that are used for gathering information and may be more
appropriate after Engaging has taken place. Even when gathering client
information, it is better to provide clients the opportunity to elaborate by
using an open-ended question, such as “Tell me about your racial or ethnic
identification,” instead of “What race do you identify with?” Sometimes
closed-ended questions can generate some lengthy answers, depending on
how they are framed.
Overall, questions should be used sparingly in MI interviews, so as to
keep you out of the question–answer trap, described below. While reflec-
tions are difficult (but get easier with practice), using them instead of ques-
tions helps to make the interaction more of a collaborative partnership.
Clients typically provide even more information in response to a good
reflection than they would have to a specific question. If the relationship/
engaging is established, clients will often tell us what we need to know
without our ever having to ask a question.

Step 2: Empathic Resonation

When clients speak, they may provide us messages that are quite direct,
or their messages may be vague or unclear, or they may not necessarily
express what they mean (Miller & Moyers, 2014; Miller & Rollnick,
2013). So after clients speak, you work to figure out what exactly they are
trying to tell you. You aim to understand their perspective and may need
to take a guess as to what the real message is. All of this is filtered through
your knowledge and experience and you strive to put aside our own values,
reactions, and expectations.
A young undergraduate social work student reported that on her
first day at her internship at a substance use treatment program, a cli-
ent approached her and asked if she was in recovery. When she said no,
that client then stated, “I don’t listen to anyone who isn’t in recovery!”
The intern’s gut reaction was to defend herself (reactance theory) and
she launched into an explanation of her background, education, and the
like. The student knew she didn’t handle this the way she wanted. As we
reviewed the client’s statement, using an MI perspective, I asked her what,
if anything, she knew about this particular client or the clientele served by
52 ELEMENTS OF MI

the agency. She knew that most of them were either homeless or had come
to the program from prison; most had experienced some sort of physical or
sexual abuse and related trauma; most had severe and chronic histories of
drug addiction. In terms of meeting strangers, particularly those who are
young, middle class, and well educated, it would seem that at least being
in drug recovery would provide a common ground. Not trusting strangers
can be a healthy coping skill that is learned in prison or on the streets.
As we discussed these areas, the student began to experience empathic
resonation: she put herself in her client’s shoes. Given the context of the
client’s statement, it began to make sense. It is the client’s view of the world
and her experiences that frame the interactions. In using MI, you want to
understand this worldview, not endeavor to have the client understand you
and your reaction.

Step 3: Expressed Empathy through Reflective Listening

The main skill that is the foundation to expressing empathy is reflective
listening, and Miller and Rollnick describe this as the most challenging of
MI skills but one that is learnable with practice and feedback (2002, p. 67;
2013). You can repeat or rephrase what the client said, providing simple
reflections. Sometimes these are useful in the early phases of a conversa-
tion, to simply encourage clients to keep talking and have them expand
on their story or viewpoint. Typically reflections start with the word you
(Miller & Rollnick, 2013), and as MI practitioners get more experience,
sometimes even the you is dropped. Reflections are always statements, not
questions. Questions can put clients on the spot and tend to be conversa-
tion roadblocks (Rosengren, 2018). A rephrase of the statement made by
the client above might be “You listen only to those who have experienced
recovery.”
Reflections can also continue the paragraph in that you might have a
hypothesis about where the client is going next and check this out through
a reflective statement (Miller & Rollnick, 2013, p. 58). For example, a
mother may be describing how difficult it is to care for her adult daughter
who is ill with a terminal disease. She tells her social worker, “I want to
help her, but sometimes I am just too frail myself and can’t do the physical
lifting that she needs.” The social worker, in continuing the paragraph,
may reflect, “You are wondering if now is the time to see about getting
some help.” This is a complex reflection. We may make a guess as to what
clients are trying to tell us or we may reflect the emotion beneath the state-
ment. Typically, if you are closely following what clients are saying, you
won’t be too far off base. And if you are, then clients will correct you and
keep talking. It helps to think of a complex reflection as something of a
 Engaging 53

hypothesis test when you are moving beyond something that the client has
stated. You can also use double-sided reflections that help pull together
for clients the ambivalence they feel: “You learned in prison not to talk to
anyone and you know that working with counselors here will probably help
you in your recovery.”
Students and trainees who are learning MI sometimes worry that
hypothesis testing is putting words in clients’ mouths. They ask if it would
be better to cushion their reflection by introducing them with words such
as “What I hear you saying is . . . ”; or “It seems to me that . . . ”; or “From
what I can observe, it sounds like . . . ,” as it allows social workers to be
wrong and for clients to correct them. It can feel uncomfortable to utilize
reflections without this cushioning, especially when trying to practice com-
plex reflections. MI trainers encourage trainees to take a risk using “You
. . . ” statements and to see what happens (Rosengren, 2018). Taking the
I out of a reflection keeps the focus on the client, allowing for empathic
resonation and clearer expressions of empathy.
While all the types of reflections encourage clients to keep talking and
to engage in the empathy cycle with you, the value of complex reflections
over simple ones is that they help move the conversation forward (Tolli-
son et al., 2008). Studies have found that using MI-consistent behaviors
increases clients’ willingness to engage with the therapist, be cooperative,
and disclose more information (Catley et al., 2006; Miller, Benefield, &
Tonigan, 1993; Moyers et al., 2005). Also, MI-inconsistent behaviors, such
as advising, directing, or warning, are related to clients’ arguing, not being
engaged, and increasing sustain talk (Apodaca et al., 2016; Apodaca &
Longabaugh, 2009; Miller et al., 1993). Therapist use of reflective listening
and other MI skills have also been found to be predictive of clients using
change talk, which in turn is related to positive outcomes (Apodaca et al.,
2016; Amrhein et al., 2003; Moyers, Manual, et al., 2007).
What is also difficult in reflective listening is choosing what to reflect
from all the statements your clients make and deciding what kind of reflec-
tion (simple, complex, double-sided, a summary, etc.) would be most stra-
tegic. This is the directive aspect of MI, and you particularly want to listen
for client change talk (described in Chapter 5) around the client’s target
behavior (described in Chapter 4), which is the Focus of your conversa-
tion. In the above example, the initial goal or Focus of the social work
intern would be to reduce the client’s reluctance to engage. Once the cli-
ent is engaged, the intern could utilize a Focusing discussion (discussed in
Chapter 4) about the goals the client has in mind for their work together.
This helps provide the direction to move in. How and what to reflect comes
with experience as well as feedback from the client, which leads us to the
next step.
54 ELEMENTS OF MI

Step 4: Received Empathy

You can probably think of a time when you discussed an important issue
with a friend or family member and they really got what you were try-
ing to say. They probably inadvertently used a reflective statement. It felt
good to be understood, and it probably encouraged you to elaborate on
the topic. As mentioned above, one of the metaphors used in discussing
the spirit of MI is the question of whether you are wrestling with your
clients or if you are dancing. When trainees in an MI workshop hear this,
they all nod their heads in understanding. Most social workers know when
they are doing one of these two things with their clients. Received empa-
thy produces the dance. The dance is knowing that a connection has been
made and that your partner is moving in sync with you. Self-determination
theory tells you that humans have a need for relationships. Empathy via
reflective listening helps you establish the dance fairly smoothly even with
the most challenging of clients, as they feel heard and experience some
sort of human connection (Blasko, Friedmann, Rhodes, & Taxman, 2015;
Moyers, 2014).

Step 5: Fresh Expression

As clients feel connected, they are more likely to keep talking about their
concerns (Apodaca et al., 2016; Catley et al., 2006; Miller et al., 1993).
Being listened to without judgment or advice reduces resistance and allows
clients to think about the possibility of change. In Step 5, clients continue
the conversation, and the cycle continues as you utilize reflective listening
statements, particularly complex reflections and other OARS skills. Typi-
cally affirmations come later in the conversation, after you have gotten to
know clients at least a little bit (Miller & Rollnick, 2013). If affirmations
are given too early, clients may discount them, thinking, “She doesn’t even
know me!”

Other OARS Skills: Affirmations and Summaries

As mentioned earlier, affirmations are statements you make about an attri-

bute or characteristic or even a past behavior that was supportive of cli-
ent change. An example would be “You are a real survivor and when you
put your mind to something; you do it, despite the circumstances that are
thrown at you.” Typically affirmations start with “You . . . ,” with an
emphasis on who the client is or what the client has done. Telling a cli-
ent, “I am proud of you” implies a value statement and keeps the focus
on the social worker. Interestingly, in a study of therapy transcripts, Apo-
 Engaging 55

daca and colleagues (2016) found that of all of the OARS skills, affirma-
tions increased client change talk as well as reduced client sustain talk.
The authors speculated that this could be because affirmations are “an
acknowledgement of a client’s change-supportive qualities or actions, even
if not previously acknowledged or stated by the client, thereby increasing
the probability the client will follow up with change talk” (p. 64).
What is meant by change-supportive qualities? As discussed in Chap-
ter 2, asking clients about a time when they were successful at changing a
behavior (not to do with the presenting problem) and describing what qual-
ities about themselves enabled the change, allows them to identify what
they know or learned about themselves. They affirm themselves by talking
about these qualities. Sometimes a client could reply, with a shrug, “I don’t
know, I just did it.” Figure 3.2 is from Miller’s (2004) work and is a partial
listing of characteristics of successful changers. This could either be given
to clients as word prompts or they could be asked to fill this out separately.
This can also be used as word prompts for you as well, to think about a
story from a client that you just heard and the adjectives that describe the
characteristics they demonstrated: “You were very resourceful and deter-
mined in how you went about finding what you needed to . . . ”
As described above, summaries are long reflections. When you sum-
marize, you pull together what clients have told you, which in another
way demonstrates empathy by showing you are paying attention to their
concerns (Miller & Rollnick, 2013). Reflections also allow clients to hear
themselves again (first they speak, then you reflect, and then you sum-
marize). Summaries help to make connections as well as to increase self-
perception. Hence, summaries should emphasize change talk and focus on
that predominantly. When you summarize clients’ ambivalence, you begin
with the status quo (or sustain talk) and then move on to change talk,
using the word and to connect the statements. This demonstrates their
ambivalence: “You don’t really like the idea of living in a senior facility
and you also are concerned about falling. You know that being near help
is something you are interested in, and you know some people who already
live there and you like them.” I caution students regarding use of the word
but as it tends to discount what was said in front of it. Just think of hear-
ing, “You’re a pretty girl, but . . . ”—there goes the pretty girl part! The
and allows for ambivalence.

Blocks to Truly Engaging

Looking back at the empathy cycle, it can be easy to fall out of it, for at
least two reasons. One is that the default method of communication is
to rely on questions, and when you fire off question after question, you
56 ELEMENTS OF MI

Accepting Committed Flexible Persevering Stubborn

Active Competent Focused Persistent Thankful
Adaptable Concerned Forgiving Positive Thorough
Adventuresome Confident Forward-­looking Powerful Thoughtful
Affectionate Considerate Free Prayerful Tough
Affirmative Courageous Happy Quick Trusting
Alert Creative Healthy Reasonable Trustworthy
Alive Decisive Hopeful Receptive Truthful
Ambitious Dedicated Imaginative Relaxed Understanding
Anchored Determined Ingenious Reliable Unique
Assertive Die-hard Intelligent Resourceful Unstoppable
Assured Diligent Knowledgeable Responsible Vigorous
Attentive Doer Loving Sensible Visionary
Bold Eager Mature Skillful Whole
Brave Earnest Open Solid Willing
Bright Effective Optimistic Spiritual Winning
Capable Energetic Orderly Stable Wise
Careful Experienced Organized Steady Worthy
Cheerful Faithful Patient Straight Zealous
Clever Fearless Perceptive Strong Zestful

FIGURE 3.2. Some characteristics of successful changers. From Miller (2004).

fall into the question–answer trap (Miller & Rollnick, 2013): the social
worker asks a question and the client answers and then the social worker
asks another question, and so on. Questions give social workers control of
the conversation, and they keep them on the hunt for information that they
deem is important. However, a lot of gathered information may be unim-
portant to the client being interviewed (and probably unnecessary) and
this can be when a client disengages. Of course, you may be in roles where
you have to collect certain kinds of information. It is better to engage cli-
ents first by listening and later fill in the information that is needed at the
end of a meeting/conversation. On a side note, I recently observed a role
play of what was supposed to be a good child welfare demonstration of
engagement/assessment, and the social worker fired off questions and hid
behind her paperwork the whole time. I was floored and no one around me
seemed to see the problem. When I am training or teaching, I always ask
 Engaging 57

students to put away any paper and pens, and to just focus on the client
in our practice sessions. Anxiety can make them want to write everything
down; however, doing so is a barrier to truly listening.
Another reason you might leave the empathy cycle is that at times it
can be difficult to listen to someone describe behaviors or ideas that are
out of sync with your value system or even legal society (Stinson & Clark,
2017). Responding reflectively to statements regarding why it is OK to use
drugs, be in a gang, not talk to a social worker, beat a wife, neglect chil-
dren, or cause a fight can make you feel uncomfortable. This is especially
true for social workers who are in some sort of social control position,
such as those in child protective services (CPS) work or in criminal justice
settings. One version of the righting reflex (the desire to fix or correct a
problem) (Miller & Rollnick, 2013) kicks in when social workers want
to challenge these kinds of statements, or educate, warn, advise, or even
threaten clients. Their fear is that if they don’t correct them, then they
won’t be doing their job. Or, there is the worry that clients will think they
are agreeing with them. MI practitioners struggle with this problem and
work to resist the righting reflex or the desire to fix the problem for clients
(Miller & Rollnick, 2013). Some have found that a few cognitive strategies,
such as reminding oneself that advice and threats typically do not change
behavior, and that empathy does not equal agreement, can help (Rosen-
gren, 2018). Another method to resist the righting reflex is to utilize what
Miller and Rollnick (2013) term as coming alongside. In MI, you recognize
that most clients experience ambivalent feelings when thinking about mak-
ing a change. When you come alongside of your clients, you reflect the more
negative aspect of the change under discussion, also known as sustain talk.
An example might be, “Being in a gang gives you a place to belong.” For
practitioners who struggle with feeling that they are agreeing with a client’s
negative statements, reframing this as a discord-reducing method called
coming alongside helps with this worry.

Engaging Clients Who Aren’t Interested

Clients, particularly those involved with the criminal justice system and
child welfare systems, are often mandated to see social workers. Other
types of clients may include those who are not seeking social services, such
as some of those who are homeless and have mental health needs, or those
who are housed but are in unsafe situations, such as extreme hoarding
or living with dementia (Roeg, van de Goor, & Garretson, 2015). These
may be clients who are referred by family members, health care providers,
police, other social workers, and the like. Clients themselves are not seek-
ing help. Another type of clients are those who are in opportunistic set-
58 ELEMENTS OF MI

tings and have not been referred for any services nor are they seeking them
out. These settings can include emergency rooms, other health settings, or
schools, where patients/students who are there for other reasons may be
screened for alcohol or substance use disorders (SBIRT interventions, dis-
cussed in Chapter 7) (Hohman et al., 2018; Smith, 2016). Or, clients could
be patrons visiting a library. Before I present an example case vignette, the
following is some information about the context.
Some who are homeless visit libraries during the day, for a variety of
reasons. They may be there to read the paper, use the computer, doze in a
quiet place, use the restroom, get out of the weather, or simply relax in a
safe place (Ayers, 2006; Kelleher, 2013). It is unknown how many patrons
who are homeless and utilize library services have mental health needs;
however, in one survey, 24% of patrons who self-identified as homeless
indicated they would like mental health services (Kelleher, 2013). Recog-
nizing that people who are experiencing homelessness make up a portion
of library patrons, and that librarians are not trained to provide refer-
ral services or even interventions that patrons might need, the American
Library Association has created policies to support these patrons as well
as those who work in the library (American Library Association, 2012).
Some libraries have hired social workers (Wahler, Provence, Helling, &
Williams, 2020).
People who are experiencing homelessness are often wary of social
workers, perhaps based on prior interactions and program barriers, stigma,
or fear over loss of autonomy (Cohen, 1989; Rowe, Styron, & David, 2016).
Reaching out to those who are living under a bridge, camping on a city
street, or even using a library, takes a nonaggressive, careful, and respectful
approach (Rowe et al., 2016). The Projects for Assistance in Transition from
Homelessness (PATH) are programs and practices supported by SAMHSA.
SAMHSA (2010) recommends the use of MI for outreach to individuals
who are experiencing homelessness due to its focus on collaboration, being
nonjudgmental, providing autonomy support, and acceptance. They pro-
pose the following guidelines:

• Ask permission to talk with individuals instead of assuming they

want to talk.
• Create a safe and accepting space for the client to interact.
• Learn what is important to the individual and address immediate
needs.
• Find out what services the client wants and has the motivation to
pursue.
• Refrain from pushing individuals into services they do not want.
• Determine the person’s stage of readiness to change a particular
behavior.
 Engaging 59

Anyone can enter a library for many different reasons. It’s public,
nonthreatening, safe, and welcoming. The library has become a restful place
for many people experiencing homelessness in our community. The program
that I am affiliated with, Social Workers in the Library (SWITL), works to
utilize the destigmatized nature of the library to reach people who may not
seek help in other ways.
Often, the patrons seen at SWITL for a typical 20-minute consultation
are experiencing homelessness. We do not have housing to offer and I may
not have new or different information for people who are already high
utilizers of the area’s resources. Regardless, I am tasked with engaging
with the patron and working to make some sort of connection. As a social
worker, when I do not have anything tangible to offer, I am constantly
assessing for small ways that I can be of service. Initially, I want to offer
a space of listening and nonjudgmental acceptance. I want to support
each patron and make them feel seen, validated, and understood. The
simple question of “What brings you in tonight?” usually gets someone
talking. During the conversation, I am constantly listening for small bits
of information to hold on to. What resources can I offer? Can I encourage
them to see their case manager? How can I foster a little bit of hope? What
intangible thing can I give this person if I cannot provide housing?
Before I know it, the consultation is over, and I may or may not have
a specific resource or referral for the patron. Sometimes the conversation
takes a specific turn and together we came up with a plan for how to obtain
food or where to find a dentist. Using my MI skills, I try to provide a calm
and safe talking space, something that the patron may not have on a daily
basis. Sitting with someone and being fully attentive and engaged is a
simple gesture that takes the utmost care and attention. Doing that rapidly,
repeatedly, and without the ability to offer many tangible things, is very
difficult. But, as social workers, we never know the impact a small amount
of time and compassion can have. Therefore, every engagement opportunity
can be impactful and must be done with intention.

                     M aria Villegas , MSW

                     Library social worker
                     San Jose, California

• Explore ambivalence using open-ended questions and reflective

statements.
• Affirm the person’s strengths.
• Elicit and reinforce client statements using MI skills.
• Help enhance the individual’s commitment to change (SAMHSA,
2010, p. 4).
60 ELEMENTS OF MI

Vignette and Dialogue Example:

Engaging Those Who Are Not Seeking Services
The following is a sample dialogue of using MI to engage those who may
not be particularly interested in services. The target behavior of this inter-
action is to encourage the library patron to seek services for housing, if
needed, or other services that the patron may identify.
The setting is a public library in a medium-sized city. The library
employs one social worker who supervises two peer counselors and
two graduate social work students. The social worker posts open house
hours for coffee and donuts; this is an opportunity for library patrons
to enjoy as well as discuss (in private) any concerns or needs they may
have with the social worker, staff, and/or interns. The social work office
also accepts referrals from the librarians regarding patrons they are
concerned about or who seem to be having difficulty managing mental
health symptoms.
The recent referral came from a librarian who noticed a frequent
patron who appeared to be sleeping (and possibly living) in his car. She saw
him in the parking lot on her way in, before the library opened. The librar-
ian was concerned as he is an older gentleman and he couldn’t have been
there overnight, as the lot is locked until about an hour before the library
opens. She was worried about where he spent the night. While he used to
come to the library once a week or so, she now sees him there daily and
he is there all day. He is always polite with the staff but lately looks more
unkempt than he has previously. He has never been to one of the library
social work open houses nor has he reached out to any of the social work
staff. The social worker has seen him in the library in the past and greeted
him, but the two of them have never had a conversation beyond that. She
sees him in the sitting area, reading a book, and she goes over to sit in the
adjacent chair. The social worker sits quietly awaiting a good time to open
a conversation. He looks at over her. (SW = social worker; LP = library
patron; [MI skills are in brackets].)

First Encounter
SW: Hi, how are you today? Looks like you found a good chair to read
a mystery in.
LP: Yes, this is very comfortable here.
SW: Nothing like a quiet space and a good book. [complex reflection]
LP: Yes, I enjoy coming here. Everyone is very nice.
SW: I know we have said hello before but never met. My name is Rosa
 Engaging 61

and I work here, which I guess you know. I work here as a social
worker. [giving information]
LP: A social worker! I didn’t know they had libraries with social work-
ers! My name is Aaron, by the way.
SW: (Laughs.) Nice to meet you, Aaron! Yes, most people do not
expect to find a social worker here, for sure. There’s only a few
of us here. I’m wondering if you would be interested in hearing a
little bit about what we do. [simple reflection; asking permission]
LP: (Shrugs.) Sure.
SW: We do a bunch of things and one of the main things we do is
connect people to resources in the community. We know people
use the library for all sorts of things, like even doing job searches
for instance, and we can help with that. Not the looking for a
job, say, but for giving information about programs that help with
job placement or even housing. Sometimes we have parents come
with their kids who are interested in parenting classes. [providing
information]
LP: Well that’s nice. I am sure people find that helpful.
SW: Well, I hope so! I just wanted to say hello. We have an open house
with pretty good coffee and donuts every Tuesday at 10 a.m. if
you ever want to stop by, Aaron.
LP: Thank you, I might do that. Nice to meet you, Rosa.

The social worker, Rosa, made contact with Aaron, exchanged names,
and gave him some information about her role. Her overall goal is to
engage him, to learn more about his situation, and provide him with some
resources that may assist him, if he is interested. She kept the conversation
brief as Aaron is not looking for services at this time and may be wary of
engaging with a social worker and disclosing personal information. Of the
OARS skills, Rosa used mostly simple reflections and asked permission to
share a bit of information about her role, which is a way to support Aaron’s
autonomy. She kept the description fairly general and invited him to the
open house.
She stops by to see him a few days later, with Aaron sitting in the same
chair in an area that is mostly private.

Second Encounter
SW: Good morning, Aaron! How are you doing this morning?
LP: Hello Rosa—it is Rosa, right? I’m doing fine.
62 ELEMENTS OF MI

SW: You must really be a quick reader. I see you are on a different
book already. You have the ability to plow right through them.
[affirmation]
LP: Yes, I tend to read quickly. I love reading and love how it takes me
to another place.
SW: Reading is a good way to put ourselves in a different world. [sim-
ple reflection]
LP: That’s for sure, I can’t travel like I used to, so in a way, it is like
traveling.
SW: Where all have you traveled? [open-ended question]
LP: Well when my wife was alive, we went to Asia, Europe, Canada
. . . all over. I loved it.
SW: It was fun being with her and seeing all these places. [complex
reflection]
LP: Yes and now those days are gone. She’s gone and I don’t have the
funds to travel anymore, so here I am.
SW: That’s a big change to make. It sounds like you have found a
way to travel—though it isn’t quite the same, it still gets you into
another world. [complex reflection]
LP: Yes, well, you do the best you can. And the price is right!
SW: (Smiles.) True! Well, I won’t keep you from your book. Nice chat-
ting today, Aaron!

The social worker again is engaging Aaron slowly. She has learned
that he is a widower and now has limited funds. The MI skills she used
are open-ended questions, affirmations, and reflections. She used an open-
ended question regarding his travel experiences to get to know him better
and for him to feel that she is genuinely interested in him as a person. Rosa
kept the encounter brief.

Third Encounter
SW: Good morning, Aaron! How are you this morning? It’s nice to see
you.
LP: Oh, hi Rosa. I am doing OK. Just feeling a little tired today, I
guess.
SW: I’m sorry to hear that. (Waits in silence for him to respond.)
 Engaging 63

LP: (Sighs.) I just didn’t sleep well. But never mind, it will do me good
to relax here today.
SW: You had trouble sleeping and don’t feel so great today, so it’s good
to be in a comfortable place. If you don’t mind me asking, what
was going on that you didn’t sleep well? [simple reflection; asking
permission; open-ended question]
LP: There’s been a lot of things that I don’t want to bother you with.
I’ve run into some problems with my apartment building being
sold and not having anywhere else to go that I can afford. I told
you my wife died and now I don’t have her income, and the social
security I get doesn’t go very far. But I will figure it out.
SW: It sounds like you have a lot on your plate, especially with being
worried about housing. You are trying to figure out what is next.
You might not be interested, but you might remember that I men-
tioned I can provide information about resources, if that can be of
help to you in your decision making. [supportive statement; simple
reflection; giving information]
LP: That’s nice of you to offer, but I would never ask for help. I was
raised to be independent and to take care of things myself.
SW: You want to make your own decisions in your own way. If you
were to ask for some information though, what kinds of things
might be important to you? [affirmation; open-ended question]
LP: Maybe there is some program that helps with finding housing?
SW: Yes, if you are interested, I can give you some information about
a program that helps with finding long-term senior housing. Can
I ask, what is your living situation now? [giving information; ask-
ing permission; open-ended question]
LP: I had to move out of my apartment so I am living in my car, but
it’s only temporary.
SW: It’s hard when you lived somewhere for a long time and then you
get the rug pulled out from under you. Sounds like you are trying
to make do for now. I have information about the help for long-
term senior housing as well as shelters for immediate housing, or
even about safe parking lots, where you can sleep in your car in
a safe setting overnight. [complex reflection; affirmation; giving
information in a menu of options]
LP: No, no shelters! I have heard about those places. But I never heard
of a safe parking lot. Maybe you can tell me more about that and
who to contact for long-term housing help.
64 ELEMENTS OF MI

SW: Sure! Would you want to come to my office to get the info or
should I bring it back to you? [closed question]
LP: I’ll walk down to your office with you. Thanks.

In the third encounter, the library patron, Aaron, is more open to shar-
ing a little bit about his circumstances. The social worker, Rosa, waited in
silence after he said he was tired, hoping that he would expand more on
that, which he did, a little. She used a simple reflection to acknowledge
his tiredness and then asked permission to ask him why he was tired. This
supports his autonomy. Aaron chose to give more information about his
living situation and finances, but had to be asked directly about his living
situation. Rosa provided a supportive statement in the form of a complex
reflection, using the metaphor of having the rug pulled out from under him.
She continued to support Aaron’s autonomy by giving him permission to
not be interested but reminded Aaron that she could provide information.
She included a menu of options that might be of interest to him, which
again, supports his autonomy. Aaron made it clear that he wasn’t interested
in emergency shelters but wanted more information on long-term senior
housing and safe parking lots.
Overall Rosa moved slowly in terms of engaging Aaron, as otherwise
he probably would have been overwhelmed by a social worker talking to
him in a library, when he didn’t ask for it. She followed the SAMHSA
(2010) guidelines listed above, by using MI skills and not assuming that he
wanted services, and she worked to create a bit of a relationship that felt
safe. Rosa got to know Aaron a bit including what was important to him,
and did not push him into receiving services. Although this vignette was
set in a library, it could be just as applicable for social workers doing street
outreach to engage those who are experiencing homelessness.

Final Thoughts

In this chapter I have identified the first process of MI, Engaging, as an

ongoing or continual process. Engaging is establishing trust in the client–
social worker relationship, mainly through the use of empathy and the spirit
of MI. Empathy is demonstrated through the use of MI skills of open-ended
questions, affirmations, reflective listening, and summaries (OARS) as well
as asking permission and providing a menu of options. Empathy occurs as
we seek to know and understand our clients, not judge, advise, or domi-
nate the conversation. As in our case example, Engaging may occur slowly
over time or it can be done rapidly, particularly in settings where the social
worker has limited contact with clients. Even in those settings, engaging can
 Engaging 65

feel like a slow process, particularly when social workers are used to getting
down to business very quickly. However, Engaging is what I call money in
the bank, for no real work can be done unless you first establish a trusting
relationship—and you get to know your clients as people.

EPAS Discussion Questions

EPAS 1: Demonstrate Ethical and Professional Behavior

 Use reflection and self-regulation to manage personal values and maintain
professionalism in practice situations.

EPAS 2: Engage Diversity and Difference in Practice

 Present themselves as learners and engage clients and constituencies as
experts of their own experiences.

EPAS 6: Engage with Individuals, Families, Groups, Organizations, and

Communities
 Use empathy, reflection, and interpersonal skills to effectively engage
diverse clients and constituencies.

1. How is resisting the righting reflex a way to manage personal

values?
2. What has worked for you in your internship or work setting that
helps you stay on the empathy cycle?
3. How have you engaged clients as experts on themselves that is
consistent with MI?
4. Rollnick recommends 20% of an interaction be spent in Engaging.
What might that look like for you in your internship or work
setting?
 C hapte r 4

Focusing
A Conversation about a Conversation

EPAS 7: Assess Individuals, Families, Groups, Organizations, and

Communities
 Collect and organize data, and apply critical thinking to interpret
information from clients and constituencies.
 Develop mutually agreed-on intervention goals and objectives
based on the critical assessment of strengths, needs, and
challenges within clients and constituencies. (CSWE, 2015, p. 9)

Off the coast in Southern California is an archipelago of eight islands

that make up the Channel Islands. Only one island is inhabited and two
other islands have small populations due to military presence. Many of the
islands are available to day-trippers who want to hike or kayak in their
unique environment. One island, Catalina, has restaurants, hotels, and
shops as well as other interesting sites that appeal to tourists. Which one to
go to? Some are easier to reach than others, and the choice of where to visit
depends on an individual’s preferences. The visitor may wish to discuss the
options with a guide who can give ideas of what to expect, the best way to
travel there, and what to bring.
Both clients and social workers need to have a destination in mind
before they leave the harbor. Identifying that destination is the goal of the
second of the four processes: Focusing. The key to change in MI is evoking
change talk from clients (discussed in the next chapter) but what are you

66
 Focusing 67

evoking change talk about? You need to know what the target of change is,
or the target behavior (Gobat et al., 2018; Miller & Rollnick, 2013).
One thing you don’t want to do is pick which island your clients visit,
if we continue the metaphor. Nor can you tell clients the exact way to get
there, but you can provide ideas about routes other travelers have taken.
Your clients often have many concerns and might want to visit all eight
islands at once. In this chapter, I will look at how to Focus, or to have a
conversation about where your client wants to visit in the current or the
next conversation. You work with clients to prioritize their multiple con-
cerns or target behaviors, and that might include your concerns or respon-
sibilities as well. I will also look at equipoise, which is a neutral state that
you need to choose when there is no specific target behavior (Miller &
Rollnick, 2013).

Transitioning from Engaging to Focusing

In Engaging, social workers spend time building trust with their clients. It
can be a slow process, as in the example from the last chapter, or it can be
done more rapidly when the social worker or practitioner has limited or
brief contacts with clients (Rollnick et al., 2016). In the Engaging process,
clients may discuss lots of issues, which is typically the case. People lead
complicated lives and problems can snowball. Often clients wait to see a
social worker only after they feel they can’t handle certain concerns on
their own or after a court or judge has ordered them to seek help. Where
to travel to, in terms of a target behavior, could be set by the social worker,
but that isn’t effective. As health care and mental health care have become
more patient-centered, Focusing, in which the patient or client takes an
active role in determining goals of treatment, has become prominent (Fran-
kel, Slayer, Bonfils, Oles, & Matthias, 2013). The purpose is to determine
and include the unique needs, circumstances, resources, and concerns of
each client or patient, some of which may go beyond what the health care
provider (or social worker) may perceive as their needs. The National Insti-
tute for Healthcare Improvement (NIHI) has moved in this direction with
an initiative about not asking, “What’s the matter with you?,” instead ask-
ing, “What matters to you?” (NIHI, 2020).
In the Engaging process you may learn about the values, aspirations,
concerns, and/or strengths of clients. You build trust and also learn about
what matters to your clients, so your conversation could take a variety of
directions. Depending on the setting and time available, you move on to
Focusing to help decide the target behavior. You also are on guard against
premature Focusing. This is where you might decide what the problem is
and narrow the conversation to that. Often this is based on your experi-
68 ELEMENTS OF MI

ences with other clients, instead of listening to what this particular client
has to say (Miller & Rollnick, 2013). Doing so is a method of dis-Engaging!
As you feel a transition in the initial conversation, that clients have
become Engaged, a summary is useful to pull the various topics that have
been discussed, however lightly, together. This summary leads to what the
rest of the conversation (or future conversations) will cover. The social
worker then asks clients how they would like to use the rest of the time in
the meeting or what they would like to focus on.
I will use the example throughout the rest of this chapter of a college
student, age 28, who has sought counseling at a university-based counseling
center. Students are typically seen for four to five sessions, depending on their
need. If there are concerns that need ongoing counseling, students are usually
referred to community resources. Debra is a biracial woman who is a veteran
and is struggling with meeting the demands of her classes. After spending
some time on the Engaging process, the social worker has learned a bit about
her. Her transitional statement to Focusing is as follows, using OARS skills:

“So far, Debra, we have talked about your concerns about being
successful in your classes, you feeling like you don’t fit in with your
classmates, and about how much you enjoy learning. But you find
the demands of being in college stressful, you’re concerned that
perhaps you smoke too much marijuana to cope, your relationship
with your partner is sometimes difficult, and that you enjoy salsa
dancing! [summarizing] You have shown some real determination,
going back to school to completely change your career, and future.
[affirmation] Thinking about what matters to you most, how
would you like to use the rest of the time we have together today?
What would you like to focus on? Or perhaps there is something
else that you would like to talk about that I haven’t mentioned.”
[open questions]

The summary brings the various topics together and gives the client a
chance to add to some of the choices that were in the summary. Again, the
social worker has to be careful not to do a premature Focus, which in this
example could be to say that Debra’s marijuana use needed to be addressed,
or that she thought perhaps Debra had posttraumatic stress disorder (PTSD)
as the real issue. In MI, Focusing is a collaborative process where clients
select which islands they want to visit first, and come to an agreement with
the social worker about other topics that may be covered. You can get to
your own concerns, eventually, and the process for that aspect of Focusing
is described below. There will be times when social workers need to bring
up an agenda item that they need to cover, based on professional insight or
organizational needs (Matulich, 2013; Miller & Rollnick, 2013).
 Focusing 69

When Clients Are Overwhelmed with Multiple Issues

As noted above, clients who meet with social workers often have multiple
concerns that may have snowballed due to various reasons, from trying to
manage them themselves to life circumstances. How can Debra decide what
to focus on since she is immediately concerned about failing classes, feels dis-
couraged that she is different from her younger classmates, has had a fight
with her partner about her marijuana use, and has given up activities she used
to do, like salsa dance? After receiving the above summary, she tells the social
worker that she is also struggling with grief, from the deaths of two friends
while she was still on active duty, adding another possible area of focus.
Similar to the metaphor of choosing an island, Miller and Rollnick
(2013) describe clients who are in a “sea of problems” (p. 105). One method
of helping clients determine a focus is through the use of a tool called an
agenda map (Gobat, Kinnersley, Gregory, & Robling, 2015). An example
of an agenda map is shown on Figure 4.1. It is a visual tool that allows
clients to organize their thoughts or to break the experience of being over-
whelmed into manageable parts. It can also be a way to include an issue
that the client may be reluctant to discuss due to stigma or shame (Rosen-
gren, 2018). The format makes it look more individualized by not having
boxes to check off about concerns, but having the client fill in bubbles with
their own topics for discussion. The map itself could be given to clients in
waiting rooms or filled out during or after discussing concerns with the
social worker (Miller & Rollnick, 2013). The goal is to identify a topic for
further in-depth discussion in the Evoking process.
As mentioned above, it is best to keep your own perspective or aspi-
rations for clients out of discussions at least until you have heard what
your clients want or how they want to proceed. You do this by exhibit-
ing curiosity and having an “uncluttered mind” that is not full of ideas
of what you think is the presenting problem (Miller & Rollnick, 2013,
p. 103; Rosengren, 2018). The social worker introduces the agenda map
and then provides time for the client to fill it out, or edit it, if they have
already done so in the waiting room. In the example, the social worker
says to Debra:

“This handout is to help organize how you want to approach our

work together over the next 4 weeks. There are some common cli-
ent suggestions in the different bubbles but they might not be what
you want, plus there are blank bubbles to write in. If it is ok with
you, can you take a look at this and fill it in? Once you are done
we can discuss the topics you have chosen and think about how
you might want to prioritize them. We can then begin with the
list you choose and also reevaluate it over our time together if you
70 ELEMENTS OF MI

Here are some of the things clients we work with have told us they would like to discuss. You may add
your own areas of concern in the empty bubbles. Which one would you like to talk about today?

Family Rela�onships
School or
Work Drug or Alcohol
Use

Healthy Ea�ng Peers

Finances/Spending
Habits

Exercise

Stress

FIGURE 4.1. Agenda mapping.

want, to see if there is something else you would like to add or to

reprioritize.”

So, as in the above statement, you can ask clients to prioritize or rank
order what topic is the most important to them (Gobat et al., 2015). Another
approach is to ask clients which one they would like to start with for that
day, whether they are being seen just once or over time. Clients may decide
on one concern but also change their mind or find something more pressing
to address as you work with them during the Evoking process. Focusing is
 Focusing 71

a way to structure your work and a change in topic is noted, discussed, and
negotiated. For example, if Debra had chosen to talk about her relationship
with her partner and wanting to improve their communication, but kept
bringing up her marijuana use, the social worker might note:

“As I look over our time together, the topic of marijuana use seems
to be moving to the forefront of our work. Is this something you
would like to focus on or explore now during our time together?”
[giving information; closed question]

Focusing helps make clear to both the social worker and the client the
direction of the conversation. Clients can raise the change of topic or it may
occur naturally as concerns are addressed (Gobat et al., 2015, 2018).

Sharing an Organizational Agenda or Your Own Agenda

Focusing or agenda mapping is a collaborative process that includes

a “shared sense of direction” (Miller & Rollnick, 2013, p. 109). In the
description above, it seems that the client is really taking the lead—as she
should. There are two experts in the room: the client and the social worker.
While clients are the experts on themselves, and you want to support their
autonomy, you also have professional skills and knowledge as well as orga-
nizational demands that certain concerns or topics need to be addressed
(Stinson & Clark, 2017). You may hear a client discuss oversleeping or
another symptom of depression without identifying or labeling it. Others
may work in settings where clients are court-ordered to do certain tasks,
such as attend substance use treatment, participate in parenting classes, get
a job, and the like. How do you raise your own concerns while still main-
taining client autonomy? How do you maintain the collaborative spirit of
the Focusing process?
Let’s start by looking at how to handle organizational agendas, such
as demands made by judges through court orders, typically seen by social
workers in probation and child welfare settings. Usually the expectation is
that clients meet all of the requirements on a court order, and they don’t
have the freedom to pick and choose which ones to work on (Stinson &
Clark, 2017). Spending time Engaging mandated clients, discussing their
concerns, and agenda mapping their concerns is a way to establish a work-
ing relationship. The social worker would next, after summarizing the dis-
cussion, indicate that the court order needs to be reviewed and discussed as
well, and topics from there added to the agenda map. Giving clients some
choice in how to prioritize their topics along with those of the court order
may help client autonomy and facilitate discussion regarding the items cli-
72 ELEMENTS OF MI

ents aren’t interested in (“I don’t need drug treatment, I just need a job”).
Using MI skills, you can explore clients’ thoughts, concerns, and views
about a specific task. Remember, when you reflect clients’ statements, it
doesn’t mean you agree with what they are saying, but that you have heard
them. Thinking one doesn’t need drug treatment may be due to a variety of
reasons: fear of repeating previous failure, not wanting to change one’s life-
style or friends, or demands of family members, for example. There could
be any number of reasons, and your job is to find out what the concerns or
barriers are in order to understand clients’ perspectives. Stinson and Clark
(2017), who work with those involved in the criminal justice system, note
that most clients are not ambivalent, underneath. They know they need
to change behaviors that harm themselves or those they love. The authors
note: “More often, it appears that a person has little interest in change only
because you have not gained their trust or listened sufficiently” (Stinson &
Clark, 2017, p. 102).
In having these difficult conversations, it is important to remember
reactance theory (from Chapter 2), which indicates that it is normal behav-
ior to react or push back through anger, defensiveness, or denial, when one’s
autonomy feels threatened (Mirick et al., 2018). This is where Engaging is
so important; you need to understand your clients, their worldviews, their
culture and values, and demonstrate this through empathy via reflective
listening (Lynch, Newlands, & Forrester, 2019; Rosengren, 2018). Engaged
clients are more likely to follow through with service or probation plans,
which in turn improves outcomes (Mirick et al., 2018). Giving choices, as
much as possible, in how to accomplish court orders or probation plans will
help with supporting autonomy and client self-determination (Stinson &
Clark, 2017). Even choosing not to comply with a part of a probation plan
is a choice, and that can be discussed in terms of what that might mean
to the client, but not as a threat. Clients are ultimately the ones who are
responsible for their choices.
At some point in the discussion, it may be necessary for social workers
to clarify their roles, especially if they are working with mandated clients.
Discussion of dual roles involves indicating the tasks of working in the best
interest of the client but also representing the court (Miller & Rollnick,
2013; Stinson & Clark, 2017). If a client appears to be suicidal or threat-
ening of a potential victim, then of course you must remind clients of the
limits of confidentiality and step aside from Focusing to complete a risk
assessment. From there, you can use MI as a brief intervention (Britton,
2015). I’d like to take a side step and look at how to possibly address sui-
cidal ideation, should it come up during Engaging or Focusing.
Suicide is a problem where most clients are ambivalent—wanting to
die and wanting to live (Britton, 2015). You don’t want to promote sus-
tain talk around suicide but MI practitioners can work to evoke change
 Focusing 73

talk around wanting to live or live talk. Live talk includes desire, abilities,
reasons, and need to live (see Chapter 5). It can also include willingness to
engage in activities that support life, such as participating in further treat-
ment, including hospitalization, locking up firearms if there is access, join-
ing in activities with the family, and the like (Britton, 2015; Britton, Bryan,
& Valenstein, 2016).
Britton, Conner, and Maisto (2012) studied the use of two sessions of
MI and a posttreatment assessment with hospitalized veterans who were
suicidal and found immediate suicidal ideation reduction in the MI group
after the second interview and at follow-up. As compared to a treat-
ment-as-usual group, those who received the MI intervention were more
likely to participate in postdischarge treatment. In a follow-up study,
the authors compared the original MI intervention that had included a
decisional balance (see Chapter 5), a revised MI intervention without the
decisional balance with more of a focus on live talk, and treatment as
usual, which did include safety planning. All three groups decreased in
their suicidal ideation but both MI groups were in the lower range (Brit-
ton, Conner, Chapman, & Maisto, 2020). More research needs to be con-
ducted regarding MI with suicidal ideation, as it holds much potential as
a brief intervention.
The spirit of MI and MI skills can still be used in these situations (Hoy
et al., 2016; Stinson & Clark, 2017). For instance, the social worker might
say:

“I am concerned about your suicide thoughts and behaviors this

week. Would you be willing to give me more specifics about that?
(Client shares.) When people feel and behave as you have this week,
I feel it’s important for me to provide options for safety. Would you
be interested in hearing some ways that we provide safety for our
students? (Yes.) Some students choose to stay home with their fam-
ily and have a safety plan used at home that includes outpatient
psychotherapy. Some students decide to go to a hospital in order to
have a more structured approach to address their suicide thoughts
and behaviors. What do you think about these options?” [giving
information; asking permission; open-ended question]

Besides the example of suicidal ideation, there may also be times when
you are working with clients where you share your own thoughts and
expertise and explore adding other items to the agenda map (Miller &
Rollnick, 2013). In the case example, as the social worker listens to Debra,
she starts to think that perhaps Debra is dealing with unresolved grief, due
to her losses of friends as well as her role in the military, where she saw
herself as capable. The social worker offers the following feedback:
74 ELEMENTS OF MI

“I’m wondering if it would be ok with you if I shared something

else that might be important to put on your agenda map? [asking
permission] You’ve shared, briefly, that you lost two friends while
serving in Iraq and you think about them quite a bit. [reflection]
You said, too, that you feel like you have lost a part of yourself
since being discharged from the military, where you had an impor-
tant job and role. [summary] Now you are in school where there
are many changes and demands. [supportive statement] I am won-
dering if it would be ok to put grief and loss on your agenda map?
[asking permission] These might have some connections to what
you are experiencing, such as your marijuana use and communica-
tion problems with your partner. We haven’t talked about it much
yet but I am thinking grief may be a key concern. What do you
think?” [open question]

Debra agreed to put grief on her agenda map but was a bit unsure as to
the seriousness of it. She asked the social worker, “So if I have grief issues,
then what? Doesn’t it just take time to get over people’s deaths?”
The social worker replied:

“We could talk about it some more to see if and how grief affects
your life. Yes, grief can lift a bit after time or it can linger and
impact daily functioning. That would be something we could
explore—how grief may be affecting you.” [giving information]

Note that the social worker asks permission to raise the topic and
doesn’t label Debra as having unresolved or even complicated grief. It
wouldn’t be appropriate at this stage, and using labels in MI work is not
helpful, as clients may react to them. The social worker also uses hypotheti-
cal language (we could explore), which supports Debra’s autonomy to not
do it if she so chose (Miller & Rollnick, 2013). If clients flat out reject a
suggestion, you don’t argue or press your point. Perhaps the topic can be
raised another time, with permission.

Direction or Equipoise?

Debra fills out her map and has chosen the following topics to discuss:
potential school failure, relationship issues with her partner, her marijuana
use, and grief and loss, all in that order. Sometimes the topics are a bit
general, and this is where her social worker can be a guide to learn more,
as they discuss these topics. As the Evoking process in the next chapter is
discussed, think about what is the behavior that the social worker might
 Focusing 75

elicit change talk around? Is there a specific island to sail toward? What do
you want to motivate your client toward? If there is no clear direction, and
you feel it would be ethically wrong to influence clients, then as a social
worker you make an intentional choice to be in equipoise, a neutral stance
where no guiding or focus on evoking change talk occurs. It is “a con-
scious, intentional decision not to use one’s professional presence and skills
to influence a client toward making a specific change” (Miller & Rollnick,
2013, p. 233).
Should Debra’s social worker guide her to avoiding school failure and
ways to think about doing that? Yes. Should she guide Debra regarding cut-
ting back on marijuana use and ways to achieve that? Yes. Should she guide
Debra regarding practicing more open communication with her partner?
Possibly, but the social worker will need to explore more about the rela-
tionship and Debra’s goals first. If Debra tells her social worker that she is
thinking of leaving her partner, should she guide her in this direction? No.
This is a clear example of where the social worker should be in equipoise.
Only Debra can make that decision. Perhaps she later tells the social worker
that her partner is physically abusive. Should the social worker guide her to
leave? Again, no, as this is her decision to make and leaving could poten-
tially put her at risk for more violence. Could a target behavior then be
making a safety plan from abuse? Yes. If Debra later tells the social worker
that her grief is having an impact on her daily functioning, should the tar-
get behavior be to guide Debra around accepting potential referrals to help
address this? Yes.
What do the Yes answers all have in common? That it would be uneth-
ical to not influence clients in the direction of health or mental health, how-
ever you might define it. The social worker’s job in working in a university
counseling setting is to promote and maximize student success. So yes, the
social worker should guide Debra toward making decisions regarding ways
to increase her chances of academic success. It would also be in Debra’s
health/mental health interest, which is also related to student success, to
guide her regarding modifying her marijuana use and accepting a referral
for grief work (if it is needed). Relationship issues are difficult and this is
where, unless she learns more, the social worker remains in equipoise.
Consider these other examples that might be heard from university
students, and think about whether there is direction or equipoise:

• Graduate school or work after baccalaureate graduation

• Moving to another city
• Donating a kidney
• Stop lying about criminal history
• Smoking
• Procrastination toward school work
76 ELEMENTS OF MI

• Intervening on a sibling’s drug addiction

• Binge drinking
• Successful probation completion
• Overcoming shyness and speaking up in class
• University education or a fine arts program
• Addressing an eating disorder
• Fear of interviewing for a job
• Telling parents about a molestation from a family member
• Revealing one’s undocumented status to friends

Some of these seem pretty straightforward and others are difficult to

ascertain, as there isn’t enough information. If you are thinking about the
concept of influence in MI, this is covered in the next chapter, on the Evok-
ing process. The questions you ask and what you choose to reflect from
clients’ statements move the conversation in a certain direction. In MI,
clients cannot, however, be influenced to do something that they don’t want
to do (Miller & Rollnick, 2013). In the next chapter, I will also look at how
to work with clients when you want to remain in equipoise and not guide
them in any one direction. In this instance, your target behavior may be to
help clients make a decision about which way they want to proceed (Miller
& Rollnick, 2013).

What Is the Relationship between Assessment and Focusing?

EPAS 7, which covers assessment in social work practice, leads to the ques-
tion of where assessment fits in all of this. How do you get the informa-
tion you might need to respond to the client helpfully? Assessment is a
key feature in models of social work practice, particularly biopsychosocial
assessments (Kirst-Ashman & Hull, 2018), where you look at client con-
cerns from micro, mezzo, and macro contexts as well as client strengths,
all within the lens of client diversity. Clearly, then, it plays a key part in the
Focusing process.
Completing an in-depth biopsychosocial assessment is often related to
the context and needs of the agency or organization. Some social workers
may only have one meeting with clients, such as in medical social work,
while others are in a limited-time setting, such as in the case example.
Those who work in mental health clinics or child welfare may have long-
term relationships and organizational requirements that usually include
such assessments. The four processes of MI can be applied to any of these
settings. No matter the context, Focusing is important to determine the
direction that the Evoking process will take. You want to engage your cli-
ents before you move on to any other tasks. If a more formal biopsychoso-
 Focusing 77

MI is a skillset that has become invaluable to me in my role as a mental

health professional working with college students. In my work with the
trans* and nonbinary community, meeting clients where they are and
genuinely believing that only the clients know what is best for them is a
place I tend to live in during our sessions. Equipoise is what comes to mind
as one of the more valuable tools I tend to gravitate toward during therapy
sessions. When clients come to meet with me, a lot of times they are in a
place of trying to figure out who they are and how their identity fits into
the world around them. There is sometimes shame, guilt, or frustration felt
in learning how to function in a traditional binary world where anything
outside of the stereotypical male/female gender options is met with
oppression. Other times there is confusion and/or self-exploration that is the
focus of the sessions. It would not be in the best interest of the client if I, as
their therapist, came into the sessions with any guiding expectations around
outcomes. This would just be reaffirming society’s desire to put people in
a box and set expectations on what their identity should be. Instead, it is
important for me to remain neutral and come from a place of openness
to the clients’ process, as they are the only ones who will know what the
outcome needs to look like. They, and they alone, determine what changes
they need to make in their lives to feel more whole, mentally, and more
spiritually and physically healthy and safe.
Using intentional language when discussing gender and identity is
extremely important, as well as maintaining a nonjudgmental stance, as
clients’ decisions may go in any direction. I utilize my OARS skills in order
to understand where clients are struggling and to gain insight into their
lives and their specific situations. Equipoise naturally enters the room as we
review the pros and cons of all decisions on the table in order to assist clients
in evaluating their own situations. These steps allow me as a clinician to
elicit each side of the scenario for clients in order for them to see what feels
right to them. Through this, we are able to fully explore the internal needs
of the individual as they relate to the world around them. In maintaining
equipoise through the session, we also empower clients in being able to fully
engage in their self-determination.

                   Soraiya K hamisa, LCSW

                   Director and therapist
                   San Diego, California

cial assessment is needed, it could be introduced after clients are Engaged,

asking permission to move in that direction. Often clients talk so much
during the Engaging process, that the need to gather information via for-
mal questions is reduced. Rosengren (2018) suggests that practitioners also
78 ELEMENTS OF MI

move to an informal MI discussion after the biopsychosocial questions or

paperwork is completed, to make sure clients are still Engaged and not put
off. It would be up to the practitioner to decide whether to engage, then
assess, and then focus, or to engage, focus, and then assess. Completing an
assessment after clients are engaged may provide more information for an
agenda map. Miller and Rollnick (2013) suggest that having clients focus
before an assessment gives an emphasis to their priorities.
In conducting a more formal assessment (or in any type of interview),
be careful of falling into what Miller and Rollnick (2013) call the question–
answer trap, also noted as a challenge in the Engaging process (see Chapter
3), whereby social workers and other practitioners ask a question, the client
answers, another question is asked, and so on. Using this method of gath-
ering information controls the conversation and perhaps controls social
workers’ anxiety as well (Stinson & Clark, 2017). It becomes a version of
the medical model whereby if the social worker asks enough questions and
gets probably more information than is needed, the social worker can then
diagnose the problem and offer a prescription to fix it (Casstevens, 2010).
Fortunately mental health care and the medical profession in general is
moving away from this model toward a focus on client-centered care and
shared decision making (Elwyn et al., 2012). MI skills, particularly reflec-
tions, affirmations, and summaries can be used throughout the assessment
process.
In the case example, Debra outlined several topics to address. The
social worker will spend time exploring each of them over their remaining
sessions. This is, in a way, almost like a more formal assessment as each
topic is covered. Evoking-type questions (and reflections) would ask about
how her schoolwork is being affected, what she has tried so far in order to
address her concerns, and what she thinks might be of help. Focusing and
agenda mapping can be used in each individual session, with the map per-
haps revisited each time (Miller & Rollnick, 2013). For social workers in
longer-term settings where treatment plans are used, Focusing and agenda
mapping can be used in the treatment Planning process, as well as once the
treatment plan or service plan has been established.

Final Thoughts

Focusing is a form of a meta-conversation, or a conversation about a con-

versation (Miller & Rollnick, 2013). Social workers guide clients to think
about what they want to talk about (as topics), perhaps raise their own
ideas and thoughts, and then discuss the order in which to proceed. This
collaborative process provides structure to the overall interactions, whether
it is in brief interventions or longer counseling work. Topics can be revis-
 Focusing 79

ited or changed, as needed, with input from clients and social workers.
Focusing is a collaborative process of negotiation through the use of the MI
OARS skills, and always, the MI spirit. An agenda map is a visual tool for
both clients and social workers to map the course that they want to sail.

EPAS Discussion Questions

EPAS 7: Assess Individuals, Families, Groups, Organizations, and Communities

 Collect and organize data, and apply critical thinking to interpret
information from clients and constituencies.
 Develop mutually agreed-on intervention goals and objectives based on
the critical assessment of strengths, needs, and challenges within clients
and constituencies.

1. How are clients’ needs prioritized in your internship or work

setting? How do you know what matters to them?
2. How does Focusing go beyond the collection and organization of
data?
3. If you were to add Focusing or even an agenda map to your work
setting, what might that look like?
 C hapte r 5

Evoking
Change Talk as the Driver of Change

EPAS 2: Engage Diversity and Difference in Practice

 Apply and communicate understanding of the importance of
diversity and difference in shaping life experiences in practice at
the micro, mezzo, and macro levels.
 Present themselves as learners and engage clients and
constituencies as experts on their own experiences.
EPAS 7: Intervene with Individuals, Families, Groups, Organizations,
and Communities
 Critically choose and implement interventions to achieve practice
goals and enhance capacities of clients and constituencies.
 Facilitate effective transitions and endings that advance mutually
agreed on goals. (CSWE, 2015, pp. 7, 9)

In MI trainings, either in the university classroom or in the community,

many trainers utilize real plays, which involve asking trainees to use actual
personal content, rather than fictional content as is done in role plays. This
allows trainees to practice MI skills as well as get a sense of how MI works
personally. One fun exercise that many trainers use is called “A Taste of
MI,” which was written by Miller and Rollnick (2013). Usually trainees are
asked to work in pairs. The pairs decide who is the speaker (or client) and

80
 Evoking 81

who is the listener (or social worker) and the speaker designates a possible
behavior change that is not too personal, such as getting more exercise, los-
ing weight, smoking, procrastinating less, and the like.
To provide a contrast to MI, sometimes I start with a real play that is
simply described as “not MI.” In this first scenario, the social worker (or
the listener) is clearly in charge: After their client (speaker) tells the listener
what the behavior is that they are ambivalent about, I ask the listener to
follow this script: Tell your speaker (1) why they should make a change, (2)
three benefits of the change, (3) how to go about doing it, (4) how impor-
tant it is to do it, and (5) to do it! Looking back on the client, Debra, in
Chapter 4, who talked about marijuana use, the directions from the social
worker might sound something like this:

“If you really want to do well in school, you can’t be smoking mari-
juana. Quitting would help you so much! You’d sleep better, feel
more motivated, and would be able to focus in the classroom. I’d
suggest that you get rid of it from your home and avoid being in
situations where others smoke it. Tell your partner that you are
quitting and that you want her help. Look, if school really means
something to you, then this is something that is important to do.
Cutting back won’t help; you need to quit altogether!”

After we do this “not MI” real play, trainees are debriefed regarding
what it was like to be the speaker or client. Every once in a while someone
who had the role of client will state that it was really helpful and that they
appreciated the ideas their listener/social worker shared. This client may
represent people who, if measured on a reactance scale, may score fairly
low, but reactance is not a personality trait as much as a response to a con-
text (Karno, Farabee, Brecht, & Rawson, 2012). Given that they were pro-
fessionals in a training setting, the speaker may have trusted their listener
or they were trying to be polite. Most trainees, however, state that they did
not feel listened to, that the suggestions made didn’t work for them, that
their social worker wasn’t interested in them as a person, and at the end,
they just wanted it to be over. They disengaged.
The pairs then switch roles to get the actual “taste of MI.” The lis-
tener/social worker is asked to conduct the interview in this way: After
your client tells you what the behavior is that they are ambivalent about,
the social worker follows this script: (1) Ask them why they might make
this change, (2) ask how they might do it if they were to be successful,
(3) ask for the three best reasons to do it, (4) provide a summary of what
you heard, and (5) ask them what they might do next. Debra, the client
from Chapter 4, might say something like this in response to her social
worker:
82 ELEMENTS OF MI

“I’m concerned about my marijuana use and think the best thing
for me would be to reduce it a bit. I’m thinking that I could not
use it during the week, especially when I have class the next day.
This might help me have more energy and study better at night.
If I tell myself these things, it might help me to not use on those
nights. I could also go to the library to do my studying. I like being
in the library as it really cuts out the distractions, and I can’t get
high there! Also, if I were to tell myself that I could still smoke on
Friday nights, then I wouldn’t feel so deprived and it would give me
something to look forward to. I really want to do well in school
and get this degree. I’ve wanted to follow this career path for a long
time. (The social worker provides a summary and asks about next
steps.) I will check out the hours for the library as well as maybe
take a look at how much I am spending on marijuana and save that
money from cutting back—maybe treat myself to something like a
spa day!”

Besides the tone of the conversation, notice how different the goal and
methods of change are when comparing the first real play to the second
one. In the first example, the social worker was the expert and assumed
that Debra, when said that she should do something about her marijuana
use, immediately jumped to the goal of quitting it, which led to the social
worker’s ideas about how to achieve that. In the second example, Debra
and the social worker had discussed an area of focus, which was that Debra
wanted to reduce her use but not quit. Debra came up with her own ideas,
such as going to the library to give herself some structure and calculating
her savings from not using during the week. Clients not only are more likely
to follow through on their own ideas, they also often come up with some
that you would have never even thought about.
In debriefing this second real-play exercise, trainees who are the
speakers/clients usually describe that they felt listened to and liked that
they came up with their own solutions, some of which they surprised them-
selves with. Not everyone is willing to take next steps but most say that the
real-play conversation certainly gave them something to think about. The
summary in particular is often described as very effective, that clients are
literally talking themselves into change by hearing their own words again,
and hearing how the social worker put it all together was motivational.
This, in a nutshell, is the Evoking process.
In the previous chapter on Focusing, I spent some time looking at pos-
sible target behaviors, or what the interview will focus on. The goal or
topic(s) is established through negotiation between clients and their social
workers, but more often than not, clients take the lead in setting their goals.
You may negotiate to add other topics based on agency or organization
 Evoking 83

requirements and/or your own professional judgment. I also considered

when social workers should be in equipoise or take a neutral position where
it is ethical to do so, such as if a client is contemplating divorce or donat-
ing a kidney. Once a target behavior is established, it becomes the island
toward which you sail by evoking and reinforcing client change talk about
it. In this chapter, I will define what change talk is, along with its opposite,
sustain talk; explore why change talk is so important and why you want to
avoid sustain talk; learn how to recognize and amplify change talk when it
arises, and methods to evoke it or increase it. Finally, I will discuss the deci-
sional balance tool, utilized when social workers need to be in equipoise
regarding a client’s target behavior.

What Is Change Talk?

Miller and Rollnick (2013) describe any discussion of change coming from
clients as change talk. Based on the research of Paul Amrhein and others,
who analyzed hundreds of MI counseling transcripts, the types of client
statements that are related to change are summarized in the mnemonic
DARN-C: change talk is any discussion of the desire, ability, reasons, need
(preparatory language), and commitment to change the target behavior.
Miller and Rollnick (2013) later added activation, and taking steps to
describe change talk, making it DARN-CAT (Amrhein, 2004; Amrhein et
al., 2003; Miller & Rollnick, 2013). The following are some brief examples
of what you want to listen for:

• Desire to change:
○ “I want to be a better parent for my son.”
○ “I wish things could be different.”
• Ability to change:
○ “I can do it; I was able to quit smoking before.”
○ “When I put my mind to something, I get determined.”
• Reasons for change:
○ “If I want to keep the courts off my back, then I need to follow
my probation.”
○ “If I come to school every day, then my grades will go up.”
• Need for change:
○ “I need for things to be different.”
○ “I have got to get a job.”
• Commitment:
○ “I will call that treatment program tomorrow.”
○ “I’ll try to see my doctor next week.”
○ “I guarantee that you will see me do things differently this time.”
84 ELEMENTS OF MI

• Activation:
○ “I looked into where AA meetings are held.”
○ “I’m ready to schedule an appointment with that doctor.”
• Taking steps:
○ “I applied for three jobs this week.”
○ “I threw out all of my drug paraphernalia.”

In contrast, client comments that stand against change are referred

to as sustain talk. Sustain talk includes statements in support of the status
quo, such as when clients tell you why they shouldn’t, can’t, don’t need
or want to change, or tell you why certain behaviors are not a problem.
Sustain talk is seen as a natural aspect of ambivalence, which most people
have when considering change. It is not pathological or a signal of being in
denial. It is normal! Even in sustain talk there might be an aspect of change
talk. Rosengren (2018) gives the example of someone who states that they
have “tried to make a certain change before and it didn’t work” as indica-
tive of someone who is at least desiring change. There is a DARN-CAT
equivalent for sustain talk as well: “I have no desire to change,” “I don’t
have the ability to change,” “There is no reason for me to change,” “I can’t
commit to doing the change,” “I won’t make an appointment with that
doctor,” and “I can’t see myself taking any of the needed steps.”
You don’t need to worry about the kind of change talk or sustain talk
you are hearing. What is important is to be able to recognize them both
and then respond so that your conversations help clients move further in
the change process (Miller & Rollnick, 2013).

Why Change Talk Is Gold

Listening for DARN-CAT talk is like panning for gold (yes, some people
still actually do it!). You pay attention to change talk and respond to it
in order to highlight it and guide the conversation in a particular direc-
tion. You let the silt and sand of the rest of the conversation filter through,
and you focus on the nuggets. Consider self-perception theory, defined in
Chapter 2, in which people learn about themselves as they hear themselves
talk. It only makes sense that you want your clients to hear themselves self-
described as capable, successful, able, and willing to make the behavior
change under discussion.
Research is now supporting the idea that change talk is gold. Research
on MI has gone from investigating “Does it work?” to examining “How
does it work?” A causal model proposed by Miller and Rose (2009) shows
that both counselor empathy and MI technical skills are predictive of cli-
ent change talk, which is then predictive of client outcome (Apodaca &
 Evoking 85

Longabaugh, 2009). The strength of commitment language is particularly

important (“I will . . . ” as compared to “I might . . . ”) (Amrhein et al.,
2003); however, other studies have found that change talk in general is
associated with change. Research has shown that MI practitioners can reli-
ably increase or decrease client change talk through MI skills or produce
sustain talk through non-MI practices such as confrontation or advice-
giving (Apodaca et al., 2016; Glynn & Moyers, 2010; Magill et al., 2014).
Sustain talk by clients has been found to be predictive of no change (Apo-
daca & Longabaugh, 2009; Apodaca et al., 2014; Baer et al., 2008; Bar-
nett et al., 2014; Moyers, Martin, et al., 2007; Moyers et al., 2009; Vader,
Walters, Prabhu, Houch, & Field, 2010). Thus, to be effective, you evoke
change talk from your clients and pay attention to not evoking sustain talk,
or softening it, if it arises.

Responding to Change Talk When You Hear It

Consider the following statements from a client who is an older adult

woman. She is discussing with the social worker at her senior center a con-
versation that she recently had with her children. They want her to give up
her driver’s license. The change talk is in bold.

“My kids have been telling me that I should stop driving, but I think
they are exaggerating. I know I’ll need to quit eventually [need], but
I haven’t had an accident in over 30 years! I did get a scare the other
day backing out in a parking lot and almost hitting another car
[reason], but that can happen to anybody. I just can’t turn around
and look like I used to [(in)ability]. I’m extra careful when I drive,
though, and I don’t drive at night anymore [taking steps]. I mean, I
would never want to hurt anybody [desire], but I just think it’s too
soon to give up my license. If I did, I’d be depending on them all
the time, and I don’t want to do that. I guess I could get rides in the
senior van [ability]. I appreciate that they are concerned about me,
but I really don’t want to give up driving yet.”

How you respond to change talk when you hear it is important, oth-
erwise it is lost gold. Using another mnemonic, EARS, a conversation can
go in several different directions. You can use (E) elaboration questions,
such as “Tell me more about. . . . ” or “What happens when . . . ?” or
“Why . . . ?”; (A) affirmations; (R) reflections; and/or (S) a summary. What
you choose to focus on guides the client either in the direction of evoking
change talk or continuing to discuss the status quo (sustain talk). Just as
clients will utilize both sustain talk and change talk, it is easy for us to get
86 ELEMENTS OF MI

caught in the silt and sand and focus on that in your responses and let the
gold nuggets fall out of the mining pan.
Although it is impossible to know how clients might respond, think
about how what is emphasized might encourage either more change talk or
sustain talk. Remember, increased change talk is related to actual change.
Here are some examples of using EARS in response to the above client
statement that could elicit either more sustain talk or more change talk.

• E (elaboration):
○ “Why do you think your children are so far off base?” → [sustain
talk]
○ “What made you stop driving at night?” → [change talk]
○ “What are the reasons your children brought this up?” → [change
talk]
• A (affirmation):
○ “You really value your independence.” → [sustain talk]
○ “You would never want to accidentally hurt anyone.” → [change
talk]
• R (reflection):
○ “The fact that your children would bring this up is really puzzling
to you.” → [sustain talk]
○ “Your children are really concerned about your welfare.” →
[change talk]
• S (summary):
○ “Your children think you should give up your license, and you
think they are off base. You almost had an accident, but this had
nothing to do with your driving skills. It was just one of those
fluke things. You will know when you are ready to quit driving.”
→ [sustain talk]
○ “Your children have approached you about giving up your license.
While you are puzzled by this, you also want to avoid ever hurting
anyone. You are worried about being dependent on them, and you
also know that your children are only saying this because they
are concerned about you.” → [change talk; describe the client’s
ambivalence]

All of these examples are demonstrations of the EARS responses to

either sustain talk or change talk from the client. You know you have picked
the wrong area to reflect or ask about when it brings up more sustain talk;
some of the statements or questions above could lead the client to further
discuss what a crazy idea her children have and how they are completely
wrong. The other questions/statements could elicit change talk regarding
the reasons or her desire to not hurt anyone. Reflecting sustain talk can be
 Evoking 87

done strategically to engage with your clients, particularly when they need
to vent or assert their autonomy. In MI, though, you want to guide the
conversation forward as much as possible, regarding the target behavior,
particularly when clients are already giving us some gold.
Here is another client. He is a man in his early 30s who has been con-
victed of driving under the influence (DUI) and is required to attend group
counseling at a local DUI program. He is meeting with his counselor for an
individual session:

“I’ve been coming to these group sessions for a while but I can tell
you, I am not like these other people in my group. They really have
problems with their drinking. I mean I learned my lesson with the
drinking and driving thing [possible commitment or taking steps],
but all this talk about having drinking problems and needing to
go to AA and to quit drinking, why that just doesn’t fit my situ-
ation. I like to drink, I can handle drinking, and I know when to
stop. My drinking is not causing me problems. I have a good job, a
good apartment, and a girlfriend, who by the way, thinks that this
whole thing is overkill for me, to have to come here. Don’t get me
wrong, you are a great counselor and all, but this all so ridiculous.
I’m fine.”

Well! Here is a client with little to no ambivalence about his behavior

under consideration. How do you use EARS with this situation? If you
do, all you end up doing is reflecting sustain talk, as this client is not even
somewhat worried, as was the elderly client in the previous situation. He
has no concerns about his alcohol use and thus finds it totally unimportant
to change. Is using EARS here a problem? As is shown in the case vignette
later in this chapter, sometimes sustain talk should be reflected, selectively,
to engage and demonstrate empathy for what the client is experiencing
(Miller & Rollnick, 2013).
This type of scenario is not unusual with clients whom you might
encounter in situations where they are mandated or court-ordered to receive
your services. It isn’t their idea to change; it is someone else’s. In these set-
tings, as social workers you have a couple of tasks. One is to assume that
there is ambivalence buried underneath the reactance (the push-back: “I’m
fine, leave me alone”) you hear from clients (Miller & Rollnick, 2013).
Much of the sustain talk can be a result of having autonomy threatened.
If client-centered theory tells us that humans are driven toward health and
positive growth (Rogers, 1959), situations that cause clients to not experi-
ence this might give them a little pause, at least somewhere in their think-
ing. Creating an open atmosphere often allows clients to move past the
reactance and to begin to consider that maybe there is a concern that they
88 ELEMENTS OF MI

have, underneath it all. Beyond using EARS, you can provide a safe space
through use of dancing with discord strategies, as presented in Chapter
6, as they work with sustain talk as well. Clients who are not pressured
to change may be more willing to examine the behavior under discussion
(Wagner & Ingersoll, 2013). Eliciting change talk strategies is particularly
useful once you have established rapport and engagement with your clients
and have moved them into a place where they feel comfortable to explore
concerns.
In the example above, perhaps the social worker could respond some-
thing like:

“You are not happy about being here and feel you are being forced
into something you don’t need. You live a responsible life and this
DUI has caught your attention.” [double-sided reflection]

This reflection covers both sustain talk and change talk and starts to guide
in the direction of signaling that the social worker sees the client’s ambiva-
lence. Note that when a double-sided reflection is given, it is joined by the
word and instead of but. The and helps clients to see that they are living
with both sides of ambivalence. Strategically, it is guiding the conversation
toward change talk by ending the reflection with the change talk, as that
is usually what clients comment on. Hopefully, this will lead the client to
further describe why his attention is caught: he can’t afford to get another
DUI, he has to protect his job, his girlfriend wouldn’t be happy with him,
and it is already costing him too much money. All of these would be rea-
sons for change, particularly if he values living a responsible life and can
describe what that means to him as well as how his alcohol use fits into that
value. The target behavior is no more drinking and driving; perhaps this
could shift as the social worker and client later explore how his drinking is
affecting other aspects of his life in an unhealthy manner.

Methods to Evoke Change Talk

There are several different strategies for evoking change talk, including
elaboration, or asking clients to explain more or give more detail; look-
ing forward or asking about what the future would be like should clients
make the change under discussion; looking backward or asking clients to
talk about a time when the behavior was not a problem or issue; and using
hypothetical language by asking what might be the best thing about mak-
ing a change. These latter three methods all work to help clients envision
how life might be different or better (Miller & Rollnick, 2013; Rosengren,
2018).
 Evoking 89

Change Ruler
There are two key aspects of change: the importance of the change and the
confidence do it. Scaling questions of these aspects using a change ruler
technique can evoke change talk as well as let you know perhaps which
aspect of behavior change (importance or confidence) to concentrate on.
For instance, a client could be low in importance to change but feel very
confident to make the change, if they decided to go in that direction. On
the other hand, clients can be high in importance in making a change but
have very little confidence in themselves to do it. Or clients could be low in
both importance and confidence: “I don’t want to change my drinking and
I doubt I could do it anyway.”
Often my students, who are beginning social workers, tell me that it
feels uncomfortable to use the change ruler because they are not used to
talking this way, that is, using scaling questions. It gets more comfortable
with practice. The ruler can be easily slid into a conversation or even given
to a client on a handout with a picture of rulers. Getting back to the client
Debra, who is thinking that maybe she should cut down on marijuana use,
you can see how the change ruler works in practice. (SW = social worker;
C = client; change talk is underlined.)

SW: I was wondering if I could ask you a couple of questions. Using a

scale of 0, not important, to 10, very important, how important is
it for you to cut back on your marijuana use?
C: A 7.
SW: Great, so pretty important! [affirms choice] Why are you a 7 and
not, say, a 3?
C: I can see how it is getting in the way of my studies. It makes me
sort of lazy and all I want to do is just sit and watch TV. I need
to focus on my homework plus be able to pay attention better in
class.
SW: (Reflects her answer.) Why else?
C: Well I’m sure I am spending more money on it than I should and I
don’t have that much money to spare as it is.
SW: So not only is it keeping you from being your best when it comes
time to focus on your homework or in class, it is costing you
money that you could use elsewhere. What would it take to make
it even more important, say to move from a 7 to a 9?
C: Probably when I see how it gets in the way of school. Or, my
partner gets upset with me for using too much, but she hasn’t
said anything so far. I don’t want to quit school, so I have to take
charge of how I am handling it.
90 ELEMENTS OF MI

SW: So, it would become even more important to you to cut back if it
continued to impact your focus in class, doing homework, cost-
ing you money, and if your partner were to say something to you
about it. Let me ask you another question. If you were to cut back
on using, on a scale of 1 being not very confident, to 10, very con-
fident, how confident are you that you could do this? [summary;
closed question]
C: Hmmm, maybe a 4.
SW: A 4, so you are in the middle of confidence. Why are you a 4 and
not a 1?
C: Well I have some confidence. I wouldn’t be where I am if I
didn’t. I didn’t use while I was deployed for obvious reasons
and I was able to quit then. I needed to keep my mind sharp
plus I didn’t want to have any legal problems. Also, now I don’t
use ALL the time. I pick and choose when I smoke so I can
control it a bit.
SW: You were able to not use at all when you were deployed and even
now you are selective about when you do use. How do you do that
now? [summary; open question]
C: Right now I am in the National Guard and have to report once a
month for the weekend. I don’t use before I go or during my time
away and I don’t even miss it. I tell myself that I don’t want to have
a problem so I don’t do it. But I am keeping busy so maybe that is
why I don’t miss it.
SW: So keeping busy and being accountable to someone else seems to
help. You are able to not use during that time. What would it take
to make you even more confident that you could cut back other
times, say to move from a 4 to a 5 on confidence?
C: Probably to just do it. To go the library and be busy there and not
be at home around the TV. Maybe if I shoot to do this two nights
a week; this would raise my confidence.
SW: What else?

Debra and the social worker go on to talk about how else Debra could
raise her confidence, using her own ideas, and the social worker reflects her
statement and then summarizes the whole conversation.
As you can see in this dialogue, it is fairly important to Debra to cut
back and she is somewhat confident that she can do it. At some point they
could discuss barriers to her cutting back, which is really evoking sustain
talk, but this might be helpful to examine only after much change talk, par-
ticularly with Debra talking about all the strengths and coping strategies
 Evoking 91

she already has. The social worker could finish the conversation by sum-
marizing it all and even re-asking the change ruler questions. People often
go up in their numbers after such a conversation.
In using the ruler, the social worker affirmed the number Debra stated.
Sometimes I get asked, “What if they pick a 0?” Perhaps the best response
is an accurate reflection: “So it is not at all important to you to . . . ” and
see how the client responds. Most people do not pick 0, however. Usually
they pick something a little higher. When asking a client why they picked
the number they did, always compare it to a lower number in order to
get change talk. Asking why the number isn’t higher is asking for sustain
talk, which isn’t helpful; however, asking what it would take to make the
change more important or to increase confidence evokes more change talk.
Note how the social worker asked her, “Why else?” twice, which increased
the amount of change talk. As noted above, people come up with answers
that surprise themselves sometimes. They may be internally examining the
target behavior against a value or past life event or something you know
nothing about. The more you can evoke, the better your summaries, and
the more clients hear themselves.
When someone has very little confidence, how can social workers
help increase it? In the above dialogue, you saw that Debra was asked why
she was a 4 and not a 1, or had some confidence. She went on talk about
the reasons why, with further discussion regarding how she currently
structured her marijuana use. Providing affirmations, reflections, and
summaries, based on Debra’s words, are ways for Debra to hear about
herself as capable, which hopefully increases her confidence. Further, the
social worker could ask her about a time when she made a different type
of change and affirm Debra through that discussion. Asking about posi-
tive attributes or strengths is another way to increase hope and the confi-
dence to move forward. As Miller and Rollnick (2013) stated, “The seeds
of hope are already there, waiting to be uncovered and brought to light”
(p. 214).
Sometimes the target behavior for the change ruler may be discov-
ered in discussion with clients around their values or things that motivate
them. For instance, with the elderly client, while the topic was the decision
to give up her driver’s license, the change ruler technique could be used
regarding how important it was for her to not endanger anyone else or to
remain independent. Most likely both of these alternatives are important;
then the client’s confidence to remain safe on the road, or to be indepen-
dent even without a license, could be explored. For the DUI client, chang-
ing his alcohol use (in general) was not important, however not having a
second DUI was. Raising the importance of that as the target behavior
could lead to (eventually) more discussion regarding the overall role of
alcohol in his life.
92 ELEMENTS OF MI

As a clinician in a community clinic, I am referred patients struggling with

mental health symptoms that are usually related to their physical health. I
work collaboratively with a multidisciplinary team to provide an integrative
treatment approach. Our goal is to have our patients feel supported,
knowing that all their health needs are being acknowledged. For example,
I’ll be asked to see someone with symptoms of anxiety and depression due
to worries related to their uncontrolled diabetes. Through MI, I can help
elicit change talk associated with building confidence as well as behavior
modifications that can help the individual take control of their health.
Ambivalence is a common barrier with the population I serve. Being
so close to the U.S.–Mexico border, we serve a large Latinx population and
some cultural values can be a strong barrier to change. For many Latinx,
it is hard to think about making any dietary changes, and acknowledging
their own health needs can be difficult. Some of the limitations I have
encountered are fixed incomes, lack of access to healthy food, limited time
to cook healthy meals due to extensive work hours, and limited insight
about the impact of life stressors on their health. Psychoeducation, empathy,
reflective listening, and adjusting to my client’s own goals and needs helps
us to work together. As a Latina I can also use my personal experiences with
these limitations and access cultural factors that can relate to my patients’
experiences. For example, by using dichos (metaphors or cultural sayings)
I make personal connections with my patients that help strengthen the
cultural and clinical relationship. For me, using MI in an integrative health
setting has been key to building trusting relationships with my patients in
an environment where they feel supported and where their behavioral and
physical health needs are being addressed.

                   C laudia G onzalez , MSW

                   Clinical social worker
                   San Diego, California

Values Exploration
In order to increase ambivalence or the salience of a concern to a client, you
can use strategies to develop discrepancy. As discussed in Chapter 2, devel-
oping discrepancy was an early concept in MI and was based on Festinger’s
(1957) dissonance theory. In this theory, humans have certain attitudes
and goals, or motivators, and being out of sync between one’s ideal self
and one’s current self can create discomfort. When the discrepancy or dis-
comfort is great enough, the person (client) may be ready to make changes.
Speaking about change out loud causes clients to think about it, perhaps
in ways they haven’t done in the past (self-perception theory; Bem, 1972).
Using methods to elicit change talk can create an increase or a shift in your
 Evoking 93

clients’ ambivalence, particularly if the problem under discussion has been

fairly low on importance. The change comes from clients’ own thinking
and discussion of the issue. If you can help them do this in an autonomous-
supportive manner, clients are more likely to make a shift.
Social work education is typically rich with emphasis on the values
and ethics of the profession, and most of us are quite familiar with those
advocated by the National Association of Social Workers. Values have been
defined as “what is good and desirable” (Dolgoff, Loewenberg, & Har-
rington, 2005, p. 18). They have also been called “behavioral ideals or pref-
erences for experiences” (Wagner & Sanchez, 2002, p. 285). While social
workers hold similar professional values and know what they are, there is a
diversity of values held by humans. People don’t often stop and take stock
of what their values are and how they measure up to them. Doing so can be
an impetus to change (Wagner & Sanchez, 2002).
Values, hopes, and strengths can be evoked by questions that focus
on the client’s life outside of the context of the problem that has led them
to you. Asking about what is important to the client, or how others would
describe them, or goals for the future can open doors to all kinds of conver-
sations. These questions or others similar to them can be a way of getting
to know clients, perhaps as part of the Engaging process or even during the
Evoking process (Rosengren, 2018).
A more structured exercise is the personal values card sort (VCS; see
www.guilford.com/add/miller2/values.pdf) created by Miller, C’de Baca,
Matthews, and Wilbourne (2001) as a way to help clients reflect on their
values. It is especially well suited for those with little to no ambivalence, as
the focus initially is more on what is important to clients and away from
discussions of the target behavior. Analyzing values and the distance clients
may be from them can help to develop discrepancy.
The VCS is a list of 100 values that can be cut up into small cards.
Examples of the values include acceptance, achievement, compassion,
excitement, fame, friendship, health, intimacy, purpose, self-acceptance,
and wealth. While there are many variations on how to use the cards, one
is to ask clients to sort through the cards and make five piles: those that
are “least important to me,” “not important to me,” “neither important
or unimportant to me,” “somewhat important to me,” and “important to
me.” The “most important” pile is limited to 10 cards. Next, have clients go
through the “most important” and discuss what each card (value) means to
them. Ask how clients are living the value, with plenty of reflections as they
are discussed. Clients can then be asked how they are not living the value
and what is getting in the way, and/or what the relationship is between the
values and the target behavior (Rosengren, 2018). In this instance, the DUI
client could be asked how drinking impacts the values he has selected. Your
role is to provide reflections and summaries throughout the process in a
spirit of acceptance.
94 ELEMENTS OF MI

Decisional Balance
While initially included in MI as a method to explore both sides of ambiva-
lence, the authors have moved away from using decisional balance as a tool
when there is a specific target behavior (Miller & Rollnick, 2013). In using
this tool, what the social worker ends up doing is evoking a lot of sustain
talk from clients, and this has been found to be ineffective in resolving
ambivalence (Miller & Rose, 2015). The decisional balance tool is used
when there is equipoise (or when you want to be neutral) in the discussion
in terms of guiding toward a specific target behavior (Miller & Rollnick,
2013). It is a structured exercise to weigh out both the pros and cons of a
decision. Sometimes it is drawn in a diagram of four quadrants, and clients
are asked to consider each section and write them in. The headings are the
pros and cons of making a change and of not making a change. In a situa-
tion where the social worker is neutral, it helps clients examine all aspects
of a decision.
In the elderly client instance, the social worker may have no indica-
tion that the client is a dangerous driver. Her goal in using decisional bal-
ance would be to help her client decide for herself what the best course of
action might be. The social worker might state, “I have no idea whether
you should give up your license or not. I can’t give you advice and I should
be neutral on the decision. Thinking about it, though, what would be the
benefits of continuing to drive? What would be the negatives or downside
of continuing to drive? What would be the downside of not driving any-
more? What would be the benefits of not driving anymore?” The social
worker can reflect these answers back to the client in a summary, using an
“and” between them all. This gives clients a chance to examine all sides
of their ambivalence that can exist simultaneously. To avoid inadvertently
guiding in any one direction (which can happen in a summary), it is even
better for the social worker to ask clients to sum up what they see as the
pros and cons. Perhaps the client can’t make a decision, as ambivalence is
difficult, and she wants the social worker to tell her what she should do.
A way to follow up on this might be to ask about her thoughts on how to
make this decision and who, if anyone, might be in the best position to help
her. In this example, the target behavior has moved to the client seeking
help to make a decision.

Vignette and Dialogue Example:

Engaging, Focusing, and Evoking

The setting is a primary care health center that provides integrated care.
It is located in a city with a large Latinx population. Victor Salcido is a
 Evoking 95

social worker who is responsible for psychotherapy and case management

of patients who are referred to him by the center physicians. The range of
patient concerns that he may see includes mental health problems, sub-
stance use recovery, and physical health management.
His client, Fernanda Bermudez, is a 51-year-old woman who is of
Mexican and Indigenous heritage. She came to the United States when she
was an infant with her parents and older sister. Her parents retired and
moved back to Mexico about 10 years ago and her sister recently joined
them. She is the mother of twins, age 18. Mrs. Bermudez and her husband
were in a car accident about 2 years ago and her husband was killed. She
suffered many injuries including a severe one to her back, which required
hospitalization and a lengthy stay in a rehabilitation center. Her sister cared
for her children while she was hospitalized. After her discharge from the
rehabilitation center, she returned to her apartment with her children and
has had difficulty with pain and mobility.
Her physician initially referred her to the social worker due to con-
cerns about possible depression and anxiety. The social worker, Victor,
worked with her regarding referrals to obtain physical therapy as well as to
see a psychiatrist for assessment and medication. He also continues to pro-
vide cognitive behavioral therapy to assist Mrs. Bermudez with her daily
functioning. With the medication and therapy, Mrs. Bermudez started to
feel better and found that physical therapy was helpful as well. She has
begun to feel well enough to return to her employment working in a real
estate office, on a part-time basis.
Recently Mrs. Bermudez was diagnosed with Type 2 diabetes. She
was provided information about diabetes management from nursing staff.
Today Mrs. Bermudez has had a follow-up appointment with her primary
care doctor and goes to meet with Victor afterward. The doctor reported
that her A1C, or blood sugar, level is high. He would like Victor to discuss
diabetes management with her, and has called Victor to request that he do
so. Both doctor and social worker are concerned that this diagnosis could
impact Mrs. Bermudez’s depression and cause her to spiral downward,
reversing the gains she has made. (SW = social Worker; PT = patient; [MI
skills are in brackets]; change talk is underlined.)

SW: Hi, Fernanda, it is nice to see you again. How are you today?
PT: OK, I guess. I think I am doing a lot better, especially with walk-
ing.
SW: That’s great to hear. It is getting easier for you to get around and
do a lot of the things you used to do. How are the twins doing?
[simple reflection; open question]
PT: Well, Sonia is working full time now which is great and Lucas is
96 ELEMENTS OF MI

looking for a job. They both start at the community college next
week. They are doing well. They try to help at home with chores
but they are also gone a lot, you know how teenagers are.
SW: They are living full lives with lots of changes, too, with college
starting. [complex reflection]
PT: Yes, I hope they will do all the school work. They both seem moti-
vated.
SW: That’s great. And how are you making out? [open question]
PT: Like I mentioned, I am getting around better and I like being back
at work. It is good to be around other people and I can tell that
just being there improves my mood. My depression is much better.
I feel like I am living life again. At least until this diabetes diagno-
sis. That has thrown me a real curve. I just don’t feel like having
to tackle a whole new problem, especially since I have been doing
so well.
SW: You have made a lot of strides, pun intended! You’ve basically
learned how to walk again as well as adjust to being a single
mother and deal with your and the twins’ grief and sadness. You
followed through on appointments with your physical therapist
and psychiatrist and have made the best use of them. [summary/
complex reflection of past successes]
PT: Yes, you’re right. I just don’t want to have to deal with this now.

The social worker has had a relationship with Fernanda and can move
quickly into discussing her concerns but he still must spend some time in
the Engaging process. He calls Mrs. Bermudez by her first name, as this is
something she had requested of him in their first meeting. Cultural values
are important in working with Latinx clients (Olvera, Fisher-Hoch, Wil-
liamson, Vatcheva, & McCormick, 2016). For instance, showing respect,
or respeto, is one aspect of honoring a culture and typically a social worker
would start by using the formal name of the client. Other key cultural
concepts are platicando (taking time to chat), personalismo (personalized
or individualized interactions), and familismo (focus on the family), all of
which are consistent with MI (Añez et al., 2008; Zuñiga, 1992). Victor asks
about her children and then asks an open question about how she is doing.
Fernanda provides some change talk describing how she is doing better
and also brings up how upset she is about being diagnosed with diabetes.
Victor affirms her by commenting on her past successes. He then moves on
to Focusing:

SW: Fernanda, it sounds like you are upset with the diabetes diag-
nosis. It feels like a real blow on top of the hard work you have
 Evoking 97

been doing. How would you like to use our time together today?
Your doctor is concerned about your diabetes management and
we could talk about that, perhaps one aspect of it, or we could dis-
cuss anything else you have on your mind, like about your work,
physical mobility, your children, or depression medication. What
would you like to talk about today? [complex reflection; open
questions]
PT: I know I need to get my blood sugar under control. (Sighs.) I sup-
pose that is what we should talk about. I am just so unhappy
about this.
SW: You would like to talk about maybe two topics: how unhappy you
are with the diagnosis and what that means for you, as well as to
think about how you might move forward with ways to manage it
that would work for you. [complex reflection]
PT: Yes, both.

While it is recommended to not go asking for sustain talk, in this

instance Mrs. Bermudez has made it clear that she is very upset with receiv-
ing this diagnosis, especially on top of everything else she has been through.
Victor felt this needed to be acknowledged and discussed before they could
move forward. This is part of the art of MI, where the decision to discuss
sustain talk is determined by the context and needs of the client (Miller &
Rollnick, 2013). Too much of a focus on sustain talk, however, may leave
Mrs. Bermudez feeling even more overwhelmed and even hopeless (Miller
& Rose, 2015). Victor has to balance both sustain and change talk with an
emphasis on change talk.
Because he had an hour to meet with Mrs. Bermudez, he had the time
to cover diabetes self-care as the target behavior, as they discussed the vari-
ous components. If, in another situation where there is less time, such as
when Mrs. Bermudez meets with her doctor, the doctor may ask her to think
about a specific behavioral aspect of diabetes self-care for their focus. Mrs.
Bermudez, in her meeting with Victor, may have wanted to talk about some-
thing completely different from diabetes self-care. If that was the situation,
then Victor would need to negotiate that he also needed to cover some ways
to reduce her A1C levels, as requested by the doctor. Victor would, however,
begin with the area of focus that was most pressing to Mrs. Bermudez.
Because she raised diabetes self-care herself, they were in agreement of this
as a target behavior. Next he moves on to the Evoking process:

SW: What was it like for you when Dr. Muñoz told you that your A1C
levels came back indicative of diabetes? [open question]
PT: I was in shock. Yes, I was feeling tired, had headaches, and seemed
to be hungry and thirsty all of time but I thought that was due to
98 ELEMENTS OF MI

the depression meds. I figured those were side effects that I had to
live with. I was stunned when he told me it was Type 2 diabetes.
SW: You weren’t feeling well but you thought it was from your meds.
[simple reflection]
PT: Yes, I just couldn’t believe it. Next thing I know I was talking to
the nurse and she gave me all kinds of information, but I could
barely process it. I just said, “OK, OK,” to her but left here in
shock. I looked at the information at home and did a little bit of
what was suggested. I have avoided some carbs but it is next to
impossible for me to exercise. I am lucky that I can walk to my car
and then walk to my desk at work.
SW: Even though you were stunned at the news, you went home and
began to implement some of the changes that were recommended,
such as cutting out down on carbs. You know that physical activ-
ity is also important. What else do you know about what you
might need to do to manage the diabetes? [simple reflection; open
question]
PT: I don’t really remember. Maybe I just want to block it all out. Diet,
exercise, drinking water, monitoring my blood sugar levels, tak-
ing my meds. I guess that is about it.
SW: You remember quite a bit and you started in already on making
some lifestyle changes. You are certainly one determined person! I
have seen that in you: when you put your mind to something, you
really follow through. Cutting down on carbs for instance is not
an easy step and it sounds like you took this one on. How did you
do it? [affirmation of current successes; open question]

Fernanda went on to explain the steps she took to modify her diet as
well as to remember to take the medication. She had some questions regard-
ing monitoring her blood sugar levels and testing, which Victor answered.
Victor returned to the topic of physical activity.

SW: I’m not saying that this is something you feel ready for, but if you
were to decide that you wanted to increase your physical activity,
what might you do? [open question]
PT: Oh I don’t know. (Shrugs.) I guess I could talk to my physical
therapist and see what she thinks I am able to do, how I might
push myself. I might be able to walk more than I think I can,
especially if I use my walker. I haven’t been using it, but I only
walk short distances right now. Maybe I could walk up and down
my sidewalk each day with my walker, and go a little further each
time. But only if my therapist says it’s OK.
 Evoking 99

SW: So one idea is to ask the physical therapist and see if you could
walk outside more if you used your walker for support. [simple
reflection]
PT: Ugh, I hate that idea, it makes me feel like an old lady and my
neighbors will see me. But if it is what I need to do, so be it. It
won’t be for long . . . probably until I could walk without it.
SW: As you look down the road, you are thinking that you will con-
tinue to get stronger physically and be able to walk more, without
any assistance, which in turn will most likely affect your A1C
level, along with the other steps you are taking. What else might
be different if you continue to do these various steps? [complex
reflection; open question of looking forward]
PT: Hopefully I will continue to improve all around, not feel sorry for
myself, and maybe even lose some weight in the process. It has
been a tough few years and not being sedentary will be good for
me. Hopefully, I won’t feel so tired all the time either.
SW: You see some benefits in that you will feel better and have more
energy for yourself, maybe even for work and your children. On
a scale of 0 to 10, with 0 being not important to 10 being very
important, how important is it for you to get a handle on diabe-
tes? [complex reflection; closed question]
PT: I’d say it’s an 8. I know my health is at risk. I would like to think it
was something that I could ignore, but I am realizing that I can’t.
It’s important for me to be healthy for my kids. They have already
gone through so much since the accident and my having depres-
sion. Sure, they are considered adults now, but they still are really
teenagers and need a healthy parent.
SW: So, you feel it’s very important to you to be healthy for your kids
and also for yourself as well, that you’ll feel better and won’t be
as tired. Another question: On a scale of 0 to 10, with 0 being not
confident at all and 10 being very confident, how confident are
you that you can follow through with what’s needed regarding
diet, exercise, medication, and blood monitoring, and as a result,
get your A1C level down? [simple reflection; closed question]
PT: Hmmm, maybe a 6.
SW: So, you are on the upside of confident. Why is it a 6 and not, say,
a 2? [simple reflection; closed question]
PT: I have some confidence, well, a little. I have come a long way from
the accident, both physically and mentally, and also emotionally.
I had to be a fighter for my kids. And I can probably fight this as
well. Maybe . . . Truthfully, I haven’t totally given up junk food
100 ELEMENTS OF MI

but I have thrown out the ice cream and cookies at home. I never
.

have liked soda drinks. Maybe I could work with a nutritionist to

really learn about the best way to avoid carbs? I would be willing
to do that. I looked a little bit at this lady on Instagram (social
media) who cooks healthy Mexican food and that gave me some
ideas. I also know that I have made progress with my walking and
that this might be something I can keep doing. That will probably
help with my depression too. I guess that the more I do all of this,
the more confident I will feel in addition to just feeling better.
SW: What would it take to, say, make you even more confident, say
move from a 6 to an 8?
PT: Probably the more I manage it, and get my A1C level in the correct
range, the better I will feel that I can do this. I know it won’t be
easy or fun, but the more I do it, then it will become more routine,
a habit.
SW: Let me see if I got all of this. It is important to you to manage
your health and you feel fairly confident that you can do all these
aspects of diabetes care, especially if you have some support from
your physical therapist and a nutritionist. You see how far you
have come since the accident and this gives you hope that you
will keep making strides. It’s a lot to take on all at once and yet
you have already started to do most of the recommendations. The
more you do it, the more likely it will become a habit. What do
you think? [summary; affirmation; open question]
PT: I feel a lot more motivated and less hopeless. I see what I have
done so far and realize that I am stronger than I think I am. This
will not be easy, but nothing ever is. You know what they say: ¡No
hay mal que por bien no venga!
SW: (Laughs.) Absolutely: ¡No hay mal que por bien no venga! (Every
cloud has a silver lining.)

Diabetes affects about 30.3 million people or about 9.4% of the popu-
lation of the United States and is higher in the Latinx population, at 12.1%
(Centers for Disease Control and Prevention [CDC], 2017). It is a major
health issue impacting many aspects of a person’s life. A diagnosis of dia-
betes is strongly related to depression (Olvera et al., 2016), as managing the
disease is difficult. Social workers are now working in this area of medical
social work, particularly in integrated health care settings. They may pro-
vide motivational work as well as education around disease management.
Wardian and Sun (2015) believe that social workers are well suited for
this role due to our counseling skills as well as our understanding of men-
tal health, and the environmental and systems contexts that affect clients.
 Evoking 101

Communicating hope is essential, as it is difficult to live with this chronic

illness that has serious implications if not managed (Olvera et al., 2016).
MI has been found to be effective in individual diseases and has poten-
tial for effective outcomes for those with multiple morbidities (McKenzie,
Pierce, & Gunn, 2015).
As noted in this vignette, both the physician and the social worker
were concerned about the patient’s coping with a new diagnosis of diabe-
tes, given all that she had been through already. Fortunately, Fernanda had
done well in her therapy and use of depression medication. In examining
the transcript with change talk underlined, you can see that her change
talk increased as the counseling session progressed, based on Victor’s use
of Evoking. Victor knew he had Fernanda’s past successes to draw on but
first listened to her sustain talk about how upset and frustrated she was.
He reflected that to let her know that she was heard, but also reflected her
change talk, about the steps she was already taking. He then asked her for
what she knew already about diabetes care and affirmed her regarding the
positive direction she was already moving in. He brought up the topic of
possibly increasing physical activity and gave her the choice to disregard
it. (He knew he could bring it up again, if needed, at a later time.) The
patient, Fernanda, began to describe her own ideas of how she could do
this. Victor evoked more change talk with a looking-forward question of
how her life might be different if she incorporated the various aspects of
diabetes self-care. He then used the change ruler to measure her views on
the importance and her confidence of managing her diabetes. He didn’t
use the follow-up question on the change ruler, that is, what it would take
to increase her importance rating, as diabetes management was already
important to Fernanda. However, he included it in the scaling questions
regarding confidence, as she was a bit less confident. The confidence ques-
tions led to a discussion around her past successes, values as a parent, and
her idea that the changes would become habits. She indicated toward the
close of the interview that she felt much more motivated and less hopeless.

Final Thoughts

The Evoking process, with its emphasis on recognizing and amplifying

clients’ change talk in a guiding, directional manner, is what makes MI
unique and different from client-centered therapy (Morgenstern et al.,
2017). Studies have found that client change talk is related to client behav-
ior change, while sustain talk is related to clients maintaining the status
quo of the target behavior (Apodaca et al., 2014; Apodaca & Longabaugh,
2009; Magill et al., 2014). During the Evoking process, it is important to
observe how clients are reacting and that they are dancing with you as
you guide them toward change (Matulich, 2013). As a good MI interview
102 ELEMENTS OF MI

moves along, sustain talk should decrease and change talk increase, as you
saw in the case vignette example (Miller & Rollnick, 2013).
Occasionally trainees of MI ask about the role of influence or persua-
sion by the therapist/social worker/counselor. By deliberately picking and
choosing which aspects of client language to reflect and summarize, are
you influencing your clients in a particular direction? Yes, you are. You do
so with open transparency about the target behavior while operating from
the spirit of MI regarding respect, collaboration, and autonomy support.
Persuasion is counter to the MI spirit. You are helping clients tap within
what is important and motivating to them. Perhaps you are influencing
your clients to persuade themselves, and you do it in the positive direction
of change. Ultimately clients make their own decisions about what is best
for them.

EPAS Discussion Questions

EPAS 2: Engage Diversity and Difference in Practice

 Apply and communicate understanding of the importance of diversity and
difference in shaping life experiences in practice at the micro, mezzo, and
macro levels.
 Present themselves as learners and engage clients and constituencies as
experts on their own experiences.

EPAS 7: Intervene with Individuals, Families, Groups, Organizations, and

Communities
 Critically choose and implement interventions to achieve practice goals
and enhance capacities of clients and constituencies.
 Facilitate effective transitions and endings that advance mutually agreed on
goals.

1. How does Evoking assist in understanding client diversity and life

experiences as well as with engaging clients and in enhancing their
capacities?
2. How might Evoking make for more effective transitions when
working with clients? How can it help move clients from
ambivalence to thinking about change?
3. Utilize the change ruler with a client at your work setting/
internship. Think about your experience and also how it may
change how you answer the first two questions.
 C hapte r 6

Client Discord
A Time to Re-Engage

EPAS 1: Demonstrate Ethical and Professional Behavior

 Use reflection and self-regulation to manage personal values and
maintain professionalism in practice situations.
EPAS 2: Engage Diversity and Difference in Practice
 Present themselves as learners and engage clients and
constituencies as experts of their own experiences.
 Apply self-awareness and self-regulation to manage the influence
of personal biases and values in working with diverse clients and
constituencies.
EPAS 6: Engage with Individuals, Families, Groups, Organizations, and
Communities
 Use empathy, reflection, and interpersonal skills to effectively
engage diverse clients and constituencies. (CSWE, 2015, pp. 7, 9)

I recently presented a workshop on MI at a statewide substance use disor-

der conference. I asked the audience, many of whom had had prior training
in MI, what they would like to discuss during our time together. Listening
skills was one topic that came up—it’s always helpful to work on reflective
listening!—and the other key request was how to work with clients who
are resistant. Lots of heads nodded in agreement—of course, clients who
are less than enthusiastic about engaging in treatment is a common coun-

103
104 ELEMENTS OF MI

seling issue. Clients in substance use treatment are often forced to be there
by the courts, probation, child welfare, family members, employers, or life
circumstances, and most are not happy about it. Indeed, MI was developed
to work with clients who had problems with alcohol or substance use and
were in this frame of mind.
As mentioned in Chapter 2, while the term resistance was used in ear-
lier works by Miller and Rollnick (1991, 2002), they have changed to the
term discord (2013). This was done to move away from the focus on the
client as having some sort of deficit. Discord is now seen as a response to
what is occurring in the relationship between the social worker and the
client. The behaviors that you see in angry, upset, or withdrawn clients are
responses to, say, court mandates, but can also be due to the interpersonal
communication between clients and the social worker. It is not a client
problem—it is a social worker problem. Ouch! This is a tough one to hear.
What this means then is that when resistant behaviors are observed, it is
your job as a social worker to stop, reflect on what just happened in the
interaction, and proceed to communicate in a different manner. This is
called dancing with discord, and strategies for how to dance are described
below.
Reactance theory states that when autonomy is threatened, humans
will react or push back to assert their freedom or control of the situation
(Brehm & Brehm, 1981). This pushback is often termed resistance by social
workers and other practitioners. Classic definitions of resistance are often
from the psychodynamic perspective, in that resistance is something that
resides within the client and serves as an obstacle to personal growth or
change (Hepworth et al., 2017). The task of the therapist is to overcome
this obstacle through interpretation or, as in the case of traditional sub-
stance use treatment, through confronting a client about their denial (Glab-
bard, Beck, & Holmes, 2005). In this perspective, people experience resis-
tance because it is painful to examine themselves. Thus, clients respond by
trying to cover up their repressed thoughts or the insights that are provided
in the therapy process. Resistance is seen as a client problem; this viewpoint
is evident when you hear social work students and their supervisors discuss
transference issues that their clients experience. When clients respond by
being argumentative, angry, or passive, it is viewed as due to something
internal that the client is experiencing. These behaviors are seen differently
through an MI lens.
As research progressed in the area of understanding client speech
within MI interviews, it became apparent that some distinction needed to
be made regarding what Miller and Rollnick (1991) had previously indi-
cated was resistance. The term sustain talk was adopted to better differen-
tiate client speech regarding maintaining the status quo from behaviors that
could indicate discord (Miller & Rollnick, 2013). Talking about ambiva-
 Client Discord 105

lence about change is normal for those who are wanting to stay the same
and yet contemplating change, and you should expect it. Use of elaboration
questions, empathic reflections, affirmations, and summaries help to guide
the process of increasing change talk. Discord is signaled by behaviors that
clients use to indicate dissonance in the interaction with us. Such behaviors
include arguing or interrupting; changing the subject; and discounting or
disagreeing with what the social worker is saying. Other clients can refuse
to talk at all, or they may take over the whole conversation (Rosengren,
2018). Thus, in my workshop, I sought to clarify what the attendees meant
by resistance. Were they talking about sustain talk (“I don’t have a drug
problem”) or about discord (“You don’t understand me at all and you’re
not even trying!”)? It turns out it was both. And both can be difficult for
the practitioner.
What can cause a client to be upset with their social worker? Man-
dated clients may approach their social worker with distrust and with their
guard up ready to argue with everything the social worker has to say in
order to protect their families or their own autonomy. Racial, ethnic, age,
sexual identity or orientation, or class differences can put clients in a wary
or cautious frame of mind in an interview, particularly if they are working
with a social worker from a large system that has a history of discrimina-
tion (Freeman et al., 2017; Rooney & Blakey, 2018; Woller, Buboltz, &
Loveland, 2007). Clients with serious mental illness may worry that they
will be judged or made to take medications. Adolescents who are work-
ing through normal developmental issues around autonomy may be highly
suspicious of anything an adult in authority has to say (Franklin, Hopson,
& Guz, 2018; Naar-King & Suarez, 2011). All of these situations pres-
ent social workers with cautious or angry clients who are meeting them
with normal responses to having their need for power and control over
their lives—that is, their autonomy—threatened. No matter the setting,
social workers are usually in a position of power, privilege, and most likely,
authority (Rooney & Blakey, 2018). You recognize this as well as appreci-
ate the normalcy of clients’ responses to it. It is then how you respond that
sets the stage for future interactions.

Discord and the Four Processes

You have seen how the context of an agency setting where there may be
authority and power issues can produce client reactance. Previous experi-
ences with trauma, racism, or oppression in society or from previous social
workers can cause clients to approach us with mistrust and readiness to
defend themselves (Miller & Rollnick, 2013; Rooney & Blakey, 2018).
Anger at being forced into a social work setting or of being controlled, or
106 ELEMENTS OF MI

fear of stigma and shame are also reasons for clients to approach a new
social worker with wariness. So, before you even meet your clients, some
may not be interested in working with you. Miller and Rollnick (2013)
note, “The good news is that in MI . . . you’re not responsible for the client’s
starting point, but you do have considerable influence over what happens
next. MI has been found to be a particularly effective approach for working
with people who are angry and defensive at the outset” (p. 207).
Beyond these contextual reasons, you can also inadvertently cause
discord during the four processes (Miller & Rollnick, 2013), basically by
being not-MI, or at least not in the spirit of MI. Sometimes social workers
in community trainings tell me, “MI is nice and all but it takes too long.
I don’t have enough time to use it.” In the Engaging process, whether it is
with a new or established client, it is easy to want to hurry along the con-
versation. You may feel you have limited time and have to get to the task
at hand immediately, falling into the question–answer or assessment trap.
Clients may respond by becoming withdrawn, passive, or angry that they
aren’t being seen as individuals. They may need time to vent about the situ-
ation and feel pressured to disclose more than what they are ready for. No
meaningful relationship is being established. If clients are coming to you
with some feelings of ambivalence, and then you cause the discord, you
certainly aren’t being efficient with your time, or effective.
During the Focusing process, you may decide on your own what the
change goal is, and this may be different from what the client has in mind
(Rooney & Blakey, 2018). If you haven’t taken the time to engage and learn
what your client sees as the issue or concern, then it may seem easier for
you (or your organization) to decide what the problem is that needs to be
addressed (Stinson & Clark, 2017). During this process you may have a ten-
dency to offer unsolicited feedback or clinical interpretation. It is also easy
to see how a client might get upset: “You don’t even understand me! I came
here asking for help with getting child care and transportation expenses,
and the next thing I know you’re telling me that I have depression and need
to get medication! I’ve had enough of this!” Labeling a problem can also
cause a client to react negatively: “You’re saying that I’m a hoarder? You
know nothing about me or my lifestyle!”
During the Evoking process, you may inadvertently cause discord by
asking about a topic that clients don’t want to discuss or guiding the con-
versation so that it is taking the conversation deeper than what clients are
ready for (Miller & Rollnick, 2013). Making a suggestion or offering advice
without permission can cause clients to stop in their tracks in an otherwise
dancing conversation. They begin to argue with you about why your sug-
gestion won’t work. They strongly argue for the status quo in an effort to
maintain power and control. A principle here is: if you hold what you think
is the right position for the client, you may damage the working alliance.
 Client Discord 107

Finally, in the Planning process, you may be under pressure and push
clients to make a treatment plan before they are ready to do so. Clients
can commit to a course of action with no intention of following through,
if only to get you off their backs. It is easy to slip into the righting reflex,
especially if you think you have a working alliance or if the behavior is
life threatening, to tell clients what they need to do or how to do it, which
can often cause discord. (Note that MI in suicide ideation intervention is
discussed in Chapter 4.) Planning, as discussed in Chapter 8, needs to be a
collaborative process.
Strategies to address client discord are presented below. If you find
yourself moving too quickly through the four processes (based on client
response: are you getting the “wrestle” instead of “the dance”?), then you
may need to return to Engaging to re-engage, or to Focusing, to renegotiate
what the focus/goal is, or to Evoking, to more thoroughly examine clients’
ambivalence, barriers, and strengths to change.

Social Worker Reactance

As a young social worker, before I was trained in MI, I worked in an

adolescent substance use treatment program. I was visibly pregnant when
I met with a client and his family. His sibling, who was also an ado-
lescent and had been through treatment himself, questioned whether I
could really help his brother and the family since he knew that I wasn’t
in recovery myself. I told him that my doctor was a man and I trusted
him to deliver my baby. The analogy was that I should be trusted as
well. I’m not sure how this helped his feelings of concern but it made me
feel better by defending myself. Unfortunately, many social workers meet
discord or sustain talk with their own reactance head on by using default
methods of communication. Other times, they inadvertently stumble right
into communication traps such as arguing or labeling (Gaume, Bertho-
let, Faouzi, Gmel, & Daeppen, 2010). Client reactance can cause even
the best MI practitioners to utilize non-MI communication (Laws et al.,
2015). These are all versions of social worker reactance, introduced in
Chapter 3.
Reactance occurs when people have their autonomy or freedom threat-
ened (Behm & Behm, 1981) and possibly when their competence is ques-
tioned. People, social workers included, can respond in a variety of ways,
such as becoming defensive, argumentative, authoritative, or blaming,
among other behaviors (Mirick, 2018). It is beyond the scope of this book,
and the perspective of MI, to describe how these types of behaviors are sim-
ilar to or different from countertransference. A study of helping profession-
als who were interviewed about clients they disliked defined their dislike
108 ELEMENTS OF MI

as countertransference while the authors defined it as negative emotions

or reactions to clients (Linn-Walton & Pardasani, 2014). Client discord
or sustain talk can cause negative reactions from social workers, thus the
CSWE (2015) EPAS twice lists competencies regarding management and
self-regulation of professional behaviors (see EPAS 1 and 2 in the CSWE
[2015] and at the opening of this chapter).
In the small qualitative study by Linn-Walton and Pardasani (2014),
practitioners, who included social workers, listed reasons for disliking cli-
ents. These reasons included clients who made them nervous due to age
differences, those who challenged them and questioned their abilities, those
who seemed resistant to change, and those who used physical intimida-
tion. In turn, the practitioners responded by blaming, labeling, lowering
empathy, name calling when not in their presence, using fear, warning, or
exerting authority.
With parallels to the results of this study of disliked clients and prac-
titioner responses, Miller and Rollnick (2013) describe communication
traps that can block communication and in the worst cases, create or
increase client discord and/or sustain talk. I already discussed in Chap-
ter 3 the question–answer trap whereby social workers might ask clients
question after question. Clients in return may not become argumentative,
but may instead go in the other direction and become overtly passive
and give minimal information, never quite engaging in the conversation.
The question–answer trap is a social worker response to the need to stay
in control of the interaction. The assessment trap is a variation of this:
asking enough questions to come up with the right answers. The blam-
ing trap is the one described in the story above: “If you don’t trust me,
it’s your fault.” All of these can be responses to having one’s competence
questioned.
A number of things that social work professionals do with clients who
show discord or engage in sustain talk can actually be counterproductive
(Forrester, McCambridge, Waissbein, & Rollnick, 2008; Mirick, 2018).
The expert trap is a version of the righting reflex. You want to tell your
clients what to do and what is in their best interests. You have lots of ideas
about how they can fix their lives. When they discount these ideas, or tell
you why they won’t work, you are surprised. Often this can come from the
demands of your organization and fear of not meeting them, and the need
to hurry clients along (Miller & Rollnick, 2013).
You can fall into the shaming trap of “I was just trying to help.” This
can be a version of the labeling trap, whereby you stick a label on the cli-
ent or behavior, such as resistant or in denial or drug addict or uncaring
mother. Warnings or threats may be made, whereby if you can’t convince
clients to make a particular change, you tell them what will happen if they
don’t make the change. You can use the taking sides trap by arguing for
 Client Discord 109

change or by agreeing with some other party who might be involved. An

example of this would be, “Can’t you see that your parents are worried
about you and only want what is in your best interest?” Finally, the prema-
ture focus trap is where you move ahead of clients, usually to the change
process, without fully exploring their ambivalence. Clients may balk at the
discussion and utilize a great deal of sustain talk to explain why they can’t,
won’t, shouldn’t make the change.
Mirick (2018) discusses another way that social workers respond
to their own reactance through what might be called another trap: self-
promotion. This is another type of response to when social workers have
their competence questioned. In return they talk either briefly or at length
about their background, training, and experience to try to convince the cli-
ent of their ability to help.
To summarize, clients may come to you ready to engage in sustain talk
or with discord, based on the context of the interview. Social worker reac-
tance can cause you to fall into communication traps that serve as ways for
you to try to exert your own autonomy by staying in control of the conver-
sation. This is done by arguing, explaining the reasons for change, discuss-
ing your competence, and the like, and usually these methods fail. When-
ever you hear a great deal of sustain talk or experience discord, your clients
are signaling to you that you are not communicating well with them—that
whatever you are doing is threatening their autonomy and they are pushing
back.

Dancing with Discord Strategies

Anyone who is not in the helping profession, reading the above material,
may think, “Why would anyone want to go into social work?” It looks like
clients come in angry and social workers may respond to them in a similar
vein. Rooney and Blakey (2018) use the term nonvoluntary practitioners to
describe social workers who work with involuntary clients and feel stuck in
their jobs due to the income, benefits, family obligations, and the like. They
may have reactance not only to their clients but to the demands of their
organization or system regarding paperwork, caseload size, and/or feel-
ings of being overwhelmed by their clients’ problems and lack of resources.
As noted in Chapter 1, MI provides strategies as well as perspectives that
help social workers not fall into their own reactance or the usual kinds of
interactions that clients have come to expect. While MI doesn’t address
work practice issues, having strategies for clients who are not easy to work
with can be helpful, especially when you see that clients for the most part
do respond well to them, which in turn can be motivating to you (Pollak
et al., 2016).
110 ELEMENTS OF MI

Bullying incidents are unfortunately common in our schools and in the

lives of our children, and are frequently referred to the school social worker
for intervention and support. As a student support staff and school social
worker, I work closely with the principal, teachers, playground staff,
students, and parents to assess, understand, support, and intervene to
differentiate between mean moments, peer conflict, and bullying, and work
toward restorative practices.
From the parent perspective, it can be very painful to find out that
one’s child is being bullied or has been mistreated. Parents send their
children to school with the expectation and belief that their physical and
emotional safety will be safeguarded, that they will be valued and treated
well. Finding out that their child has been harmed or is unhappy can
elicit a sense of vulnerability, loss, and anger. At times, the parent’s own
childhood memories may be triggered, to times when they were hurt and the
adults in their lives that didn’t, or couldn’t, prevent or stop the harm they
experienced.
Motivational interviewing is a trauma-informed and client-centered
framework and set of skills. At the onset of supporting a child and parent
with understanding what happened and moving toward strategies to
prevent and stop the harm, my focus and intention is to be present with
the individuals involved, provide a safe space to talk, express empathy,
and actively listen in order to rebuild trust and engagement. Often there
are several conflicting perspectives of the involved parties, so providing an
opportunity for the individuals involved to fully feel heard is imperative
before moving forward to determine what steps will be taken.
MI skills are essential to allaying the fears and concerns of parents
and encouraging students to meet in restorative practices circles to address
the harm and move toward genuine and authentic student-led awareness,
empathy, and amends.

                   Debbie Boerbaitz , LCSW

                   School social worker
                   Escondido, California

In the study of coping with disliked clients, respondents described

positive behaviors that helped them in their relationships with their cli-
ents. These behaviors were consistent with MI, such as seeing dislikeable
behaviors as a challenge to get past, using supportive supervision, locating
strengths in the clients to build their worthiness, using empathy as an anti-
dote to shame, and trying to see the situation from the client perspective.
One respondent indicated that he had been trained in MI and that this had
helped as well (Linn-Walton & Pardasani, 2014).
 Client Discord 111

MI strategies for addressing sustain talk include elaboration questions,

affirmations, empathic reflections, and summaries. These can be used for
discord as well. Simple reflections allow you to not get drawn into argu-
ments and at the same time they let clients know that you are listening to
them. An empathic reflection takes the wind out of the sails so to speak,
and the metaphorical boat becomes dead in the water—the energy to keep
arguing seems to dissipate. Rosengren (2018) offers this great advice:
“When a client hits us with a jolting statement, a surface [simple] reflection
can buy us some time as we figure out how to proceed more effectively”
(p. 361). A simple reflection stops the negative flow of energy and also gives
you time to gather your thoughts and think about how to best handle the
discord you are experiencing.
Discord can also come from the context, and using simple reflections
with clients signals them that you aren’t going to judge or argue your point,
but will track along with them. Amplified reflections are where you over-
state what you hear clients saying, which sometimes allows them to reduce
their pushback. Some examples of amplified reflections are given in the fol-
lowing dialogue between an adolescent client and a school social worker:

Client: Why should I talk to you . . . you have no idea what my life
is like!
Social Worker: It’s impossible for anyone to really get what you are
going through. [amplified reflection]
Client: Well, it’s not as bad as that; I have friends . . .
Social Worker: You find it really helpful to talk to your friends.
[amplified reflection]
Client: Well, we don’t really talk, but I don’t want to be discussing my
problems with some social worker.
Social Worker: So on the one hand, you’re kind of dealing with
stuff by yourself, and on the other hand, it might be nice to have
someone to discuss what is going on with you as long as you could
trust that person. [double-sided reflection]

Double-sided reflections are those that reflect clients’ ambivalence that

sometimes they can be unaware of. Using double-sided reflections helps
link both sides of the ambivalence, creating a space for the social worker to
be nonjudgmental by not taking a side. Placing what you want your clients
to remember in the last part of the reflection helps to maintain the direc-
tion of the conversation as well. In the above dialogue, the social worker
placed the last emphasis on the client’s desire to not be so isolated with the
problem the client is dealing with.
112 ELEMENTS OF MI

Other strategies have been proposed by Miller and Rollnick (2013)

for dancing with discord. One method is to shift the focus. This involves
changing the subject or steering the conversation in a different direction. In
the preceding example, for instance, the social worker could ask, “What do
you look for in people whom you trust?” This takes the conversation away
from the client’s argument that the social worker can’t understand them.
You can also shift focus in a more obvious manner, but it is done in a way
that is respectful of clients: “We don’t seem to be getting to an agreement
here. I am wondering if it would be OK to move on to another topic?”
Coming alongside is a strategy used to side with clients’ perspectives,
particularly when you hear a lot of sustain talk as to why they can’t change,
or this isn’t the time to change. My favorite example of this comes from a
role play I did with an MSW graduate student when I was a guest speaker
in a class, presenting on MI. She told me her issue was that she was a slob.
As we discussed what she meant by this, she proceeded to tell me why it
was a problem and then all the reasons why she couldn’t change. I told her,
“Perhaps now is not the time to change this; you have so much else on your
plate as a graduate student, this is the last thing you need to worry about.”
The student looked at me like I was crazy and then began to discuss all the
ways she could make the change. Coming alongside does not always work
this dramatically, but it definitely changes the momentum of the conversa-
tion. Miller and Rollnick (2013) indicate that it is important to gauge the
use of this method by making sure it decreases discord and/or sustain talk,
and elicits change talk; if clients continue in sustain talk, then perhaps a
different strategy might be better.
Agreement with a twist is an agreement or a reflection (simple or com-
plex) that has a reframe tacked on to it (the twist) (Miller & Rollnick, 2013;
Rosengren, 2018). This option helps you to align with clients and to move
the conversation in a different direction. In continuing the conversation
with the adolescent from above, the social worker might reply, “You are
careful about who you talk to and you know that when you need to, you
have found it helpful to open up to people who you trust.” The first part is
the agreement (reflection) and the second is the twist: the client didn’t say
this last part, but it was implied. The twist moves the conversation into the
direction of how the client found it helpful to talk to people in the past.
Reframing is a method that is familiar to social workers. It involves
taking something clients have said and framing it in a different way, so that
clients have a different perspective or way to look at a situation (Miller &
Rollnick, 2013). A reframe of the client’s statement that they are distrustful
of the social worker could be, “Not trusting strangers until you get to know
them is a logical way to protect oneself.” This casts the behavior as normal
with the underlying message that once they get to know the social worker,
they may be more trusting.
 Client Discord 113

Since clients may experience reactance when they feel that their auton-
omy is being threatened, then it is evident why emphasizing personal con-
trol can be an effective strategy to address this. “Only you can make the
decision about when you can trust someone,” or “The decision to change
is entirely up to you; only you can make that choice,” are two examples of
how you can acknowledge to clients that change is truly up to them. Even in
mandated settings, clients still ultimately have choices (Miller & Rollnick,
2013; Stinson & Clark, 2017).
These are social worker–client communication strategies. Some cogni-
tive strategies for working with clients whom you find difficult can include
reminding yourself that sustain talk and discord are normal behaviors for
clients, and that the behavior you are seeing is coming from the context, and
their history, not the person (Mirick, 2018). If you feel personally attacked
or questioned, it is normal to feel a bit defensive—you just don’t want to
act on it. Thinking through strategies, such as “OK, how am I going to
reflect this client’s meaning?” or “How can I respond with empathy?” or
“How can I respond differently from what this client has experienced in
the past?,” are good starting points. Remembering that discord can come
from something that you just did or said in the interaction can cause you to
pause, self-reflect, and shift gears in how you respond. Respecting auton-
omy by providing choices, sharing accurate information, not persuading,
and acknowledging feelings can reduce discord (Mirick et al., 2018).

Vignette and Dialogue Example: Dancing with Discord

A recent systematic review found that MI can be helpful in educational

settings (K–12), particularly regarding issues such as school attendance,
behavior, and academic outcomes (Snape & Atkinson, 2016). One behav-
ioral challenge for administrators, social workers, teachers, parents, and
students that is fraught with emotion for all who are involved is that of bul-
lying. Rollnick and colleagues (2016) and Cross, Runions, Resnicow, Britt,
and Gray (2018) indicate that MI can be helpful in engaging and working
with parents, students who are bullied, and those doing the bullying, and
MI can be integrated with school-based approaches that address bullying.
The setting for our example is an elementary school in a suburb of
a large, urban area. Many large biotech businesses are located there and
draw employees both nationally and internationally. As a result, the school
has a diverse student body, representing at least 15 languages other than
English that are spoken at home. Annie Kang, MSW, is a school social
worker who has been with the school district for about 10 years. She is one
of five social workers who cover its various schools. She gets a call one day
that two parents, Mr. and Mrs. Bhandari, are in the office asking to see the
114 ELEMENTS OF MI

principal, who is in a meeting. The parents did not say why they wanted to
see the principal. Annie goes out to greet them. (SW = social worker; Mr.
or Mrs. B = parent; [MI skills are in brackets]; change talk is underlined.)

SW: Hello, my name is Annie Kang. I am the social worker here for
this school.
Mr. B: We are Mr. and Mrs. Bhandari. We would like to see the prin-
cipal.
SW: Yes, I understand that you asked for her. She is tied up in a meet-
ing that will last all morning. Perhaps I can help you. Would you
like to step into my office to meet privately? [sharing information;
closed question]
Mr. B: No, we will wait for the principal.
SW: It’s important to you to speak to the person who is the head of this
school. It sounds like you have something that is very concerning
to you to talk about. [complex reflection]
Mr. and Mrs. B: (Silence)
SW: It is so concerning that you are willing to wait. [complex reflec-
tion]
Mr. B: Yes, we will wait.
SW: That is, of course, your choice. I see that you are very concerned.
Would you be willing to hear a little about what my role is as
the school social worker? [autonomy support; simple reflection;
autonomy support through a closed question]
Mr. B: Yes, of course.
SW: I’m happy to let you know. Would you prefer to do it here or would
you like to come back to my office, which is nearby? [autonomy
support through a closed question]
Mr. B: We will go to your office.
SW: Thank you. Please come this way. (Walks to the office; asks the
parents to have a seat, which they do.) Thanks for coming back
here. Would it be ok with you if I asked you a question? Would
you like to hear about my role here at the school? (Mr. B nods
affirmative.) Before I explain my role, I am wondering what you
already know about what school social workers do? [autonomy
support through an open question]
Mr. B: This is our first year in this country. We didn’t have social
workers in our son’s school in India, though of course we have
heard of social workers.
 Client Discord 115

SW: So you know a little bit but maybe not what we do in schools. I
have several different roles, including meeting with parents when
there is a concern about their child, either expressed by parents or
by teachers, as relates to their life as a student here. [simple reflec-
tion; sharing information]
Mr. B.: That’s good to know but we need to speak to the principal. We
can wait outside and not waste any more of your time.
SW: You are very committed parents. Something has happened that is
so concerning that you took off work today to come to our school.
And you want to work with someone who can change or address
whatever the concern is. It is extremely important for you to have
immediate action. [affirmation; reframe through a complex reflec-
tion]
Mr. B.: (angrily) Yes I need action! And I want to make sure that we
get answers and not just empty promises to look into this prob-
lem. That’s why I want the principal!
SW: You really care about your son and his well-being. You expect
him to come to school and be safe. [coming alongside through a
complex reflection]
Mr. B: Yes and we don’t want things to get any worse! We didn’t move
to this country, and give up being with family and friends, for him
to have these problems. It’s been hard enough on him as it is. I
doubt you have the power to do anything.
SW: It sounds like your whole family has been through a lot this past
year with many, many changes. Tell me about your son. [complex
reflection; shifting focus through an open question]
Mrs. B: Datta is in fourth grade and is a bright boy. We are very proud
of him. He seems to have made friends and plays soccer after
school. But lately he hasn’t been himself . . .
SW: He’s changed a bit. [simple reflection]
Mrs. B: Yes, he’s gotten more quiet. When I ask him how he likes
school, he just tells me it’s ok. I finally asked him if everything
was all right and he said no. He said some boys who are older are
picking on him on the playground, making fun of his name and
the food he brings for lunch. Sometimes they take his lunch and
throw it out. They tell him he should be eating American food.
Mr. B: You can see why this has me so upset! That’s why I want to talk
to the principal. What is the matter with teachers that they don’t
see when someone is being picked on? These teachers should be
paying better attention! How can our child go without his lunch?
116 ELEMENTS OF MI

SW: This is very concerning and I can see why you both came right in.
You want Datta to feel safe, not only from being teased, but to eat
his lunch in peace. You are wondering how it can happen when
there are teachers and playground supervisors who are all around
him. [coming alongside with simple and complex reflections]
Mrs. B: (tearful) And now he is saying that he doesn’t even want to go
to school!
Mr. B: Yes, we came to this community because you are known for
your schools. What good is a strong academic school when you
can’t protect your students and then they don’t even want to go?
SW: You are not only upset but frustrated. You went through a lot to
move here. You put some thought into where you wanted to live
and made the decision to pick our district. Now you are worried
that Datta doesn’t want to come to this school anymore. [sum-
mary] I wonder if I could share a little more about my role? I
support the principal by working with families here on different
issues including bullying problems or kids having a hard time
adjusting to the social or academic part of school. If there is a bul-
lying problem, I work with the student or students who have been
bullied, those who bully, and their parents to address it as well as
to prevent it from happening again. [autonomy support through a
closed question; sharing information]
Mr. B: You mean if we tell you who has done the bullying they might
get in trouble? I don’t want anyone coming after my son for telling
on someone. We just want better supervision on the playground.
That’s what I want to tell the principal. We didn’t come here to be
known as troublemakers.
SW: It is your decision for you to let me know or to ask Datta to let me
know the names of who have been giving him a hard time. Any of
you can do it confidentially. When we address reports of bullying,
we tell the student, “We received a report that you have been bul-
lying [we give the name of student] by [we describe the behavior].
If this is true, it needs to stop.” If asked who reported it, we typi-
cally say there are many students and adults in this school who
want to stop bullying and make reports. This is what we have
found to work to stop the behavior. We encourage all students
who have been bullied or who are bystanders to report bullying to
an adult. It is also up to you to decide if you want Datta to come
talk to me, about reporting this or even his feelings about school.
I can be a resource for Datta, if that is something you think he
might want. Of course, you are always welcome to talk to the
 Client Discord 117

principal. If you want, I can share your concerns with her and can
ask her to give you a call if you would like. What do you think
you might do? [autonomy support; sharing information; asking
for next steps using hypothetical language]
Mr. B.: Could you notify the principal? I will tell Datta to come see
you. He can give you the names of the students but I want it to
be a confidential report. I don’t want any repercussions for him!
I want him to know that he can let you know if there are more
problems. I will follow up with you as well. And yes, please tell
the teachers and playground staff to pay attention! It isn’t easy for
someone to be new and be from another country.
SW: I can do all that and can meet with you again, at your conve-
nience. I appreciate how much you care about your son and want
to see the situation changed immediately. For Datta, it took cour-
age for him to tell you, as most kids want their parents to not
worry. We want him to stay in this school, and to be happy. In
order to prevent bullying from reoccurring, we need to encourage
Datta to tell you and or myself if anything happens in the future.
This is how we work with the students and their parents to stop
that behavior. [sharing information; affirmation]

This vignette and dialogue demonstrates that anger and discord can
be at the start of an initial meeting, even though the social worker, Annie,
had not done anything to cause it. It is not unusual for parents to come to
a school, after a report of bullying, and be angry, upset, and overwhelmed
with concern for their child (Harcourt, Jasperse, & Green, 2014). It is also
frightening for parents who are not used to dealing with American school
systems to want to protect their child, but also not stand out in any way
either that could make them targets for more bullying. Indeed, race and
immigration status has been found to increase risk for bullying (Peguero,
2012). In this instance, the parents wanted to go straight to the principal to
make sure the situation was quietly addressed.
While respecting the wishes of the parents, the social worker used
complex reflections to try to engage them to at least meet with her so that
she could understand the situation. She repeatedly supported their auton-
omy by asking permission to share information, asking about what infor-
mation they already had regarding school social work, and also assuring
them that they were in charge of whatever decisions they felt should be
made. Her use of empathy through complex reflections, especially around
their concerns, worry, and frustration, began to increase engagement, at
least at some level. The social worker, Annie, then used a shifting focus
strategy to ask an open-ended question of “Tell me about your son,” and
118 ELEMENTS OF MI

this immediately drew the mother, Mrs. Bhandari, into the conversation.
After learning of the bullying incident, Annie used more complex reflec-
tions to come alongside regarding the parents’ need for their son to be safe.
She was able to provide information about the school’s bullying protocol
while still supporting the parents’ autonomy on how they wanted to pro-
ceed. Asking them about next steps allowed them to begin to set a plan in
place.
This was not an easy interview for Annie. Her target goal was to
engage the parents and learn what their concern was. Based on her past
experience, she suspected it was bullying. Her use of reflections regard-
ing being concerned allowed them to slowly tell her their story. She was
very patient and did not give in to her own reactance when they indirectly
questioned her authority to help them. Annie is a first-generation Korean
American who grew up with immigrant parents herself and was bullied
as a child for bringing Korean food to school, among other things. She is
also a mother of two young children. She needed to manage her own feel-
ings about her past experiences and about thinking what might happen
to her own children. Annie did not share any of this information with the
parents. Are there instances in MI where social workers could self-disclose
to clients? Typically the focus is always on the client and their experience,
so most likely not. As social workers you need to ask what the reason for
possible self-disclosure is and if it would be helpful to the client (Miller &
Rollnick, 2013). If down the road, Mr. or Mrs. Bhandari ask Annie if she
has any children, she can simply tell them yes, or in an affirmation perhaps
where she might say to them, “As a parent myself, I appreciate how com-
mitted you are to your son.”

Final Thoughts

Even when clients are not mandated to see you by a court, they still may be
coming involuntarily to some extent, such as a teenager brought to mental
health counseling by his mother. He is willing to come but not happy about
it. Other clients may have had negative interactions with social workers in
the past or may be suspicious about what might be asked of them. Discord
or client reactance can make social workers feel vulnerable and in turn we
can respond to unhappy clients in nonproductive ways, even if our response
is mild, such as making a suggestion. Understanding reactance, watching
how your clients respond to what you have to offer, and using MI strate-
gies to address discord helps you manage your own feelings as well as have
productive, and hopefully, more satisfying interactions with clients. You’ll
want the dance, not the wrestle. You will enjoy your work with people and
be less tired at the end of a day.
 Client Discord 119

EPAS Discussion Questions

EPAS 1: Demonstrate Ethical and Professional Behavior

 Use reflection and self-regulation to manage personal values and maintain
professionalism in practice situations.

EPAS 2: Engage Diversity and Difference in Practice

 Present themselves as learners and engage clients and constituencies as
experts of their own experiences.
 Apply self-awareness and self-regulation to manage the influence
of personal biases and values in working with diverse clients and
constituencies.

EPAS 6: Engage with Individuals, Families, Groups, Organizations, and

Communities
 Use empathy, reflection, and interpersonal skills to effectively engage
diverse clients and constituencies.

1. Think of a time when you may have had reactance with a client.
What was happening that caused it? How did you respond? If it
was not in an MI-consistent way, what MI strategy could you use
if you could do it over?
2. How do the MI strategies for responding to sustain talk and
discord enhance the social worker as a learner of clients’ lives?
3. The next time a client is angry with you, provide a reflective
response or two. What was this like for you? How did the client
respond?
 C hapte r 7

Sharing Information and Advice

EPAS 2: Engage Diversity and Difference in Practice

 Present themselves as learners and engage clients and
constituencies as experts on their own experiences.
EPAS 4: Engage in Practice-Informed Research and Research-Informed
Practice
 Use and translate research evidence to inform and improve
practice, policy, and service delivery.
EPAS 8: Intervene with Individuals, Families, Groups, Organizations,
and Communities
 Critically choose and implement interventions to achieve practice
goals and enhance capacities of clients and constituencies.
(CSWE, 2015, pp. 7–9)

Social Workers as Educators

Social workers are drawn to the profession for a variety of reasons. You
might say its emphasis on social justice is one aspect you love; the focus on
the person-in-environment is another. Social workers work across micro,
mezzo, and macro systems and do so in a variety of roles: therapist, case
manager, advocate, mediator, group facilitator, and administrator (Kirst-
Ashman & Hull, 2018). One role you might often play is that of educator.
You may not think of this as a specific role as it just seems to be a task that
120
 Sharing Information and Advice 121

is seamlessly interwoven into client conversations. Looking back on the

case vignettes highlighted in the previous chapters, the social workers were
educators: they had to be prepared to provide information to their clients,
for instance, on community resources, requirements and rules of homeless
shelters and safe parking lots, signs of grief and loss and ways to address it,
depression coping skills, diabetes management, and school policy regard-
ing bullying.
Perhaps it seems more accurate to say that the social workers in the
vignettes were just providing information, not educating. Many tend to
think of educating as being a little more formal, such as teaching a class, for
instance, on financial management or parenting skills. Education can also
occur in therapeutic conversations. However you define the terms, both
educating and sharing information should be interactive experiences, not
the passive reception of information by clients. Think of all the lecture
classes you sat through in college—can you remember them? Maybe, if the
content was of interest. Often, though, the lecture was easy to tune out,
and clients can also tune you out when talked at, either in a classroom set-
ting or in a one-to-one meeting or discussion. Research on adult education
has found that learning comes in the interaction between educators and
students (Sogunro, 2015). Similarly, how you educate or share information
with clients is important. Rosengren (2018) writes, “Information sharing
is not a one-way street. Clients have significant wisdom about themselves,
their situations, and what has and has not worked in the past” (p. 208).
Hence, the emphasis is on the use of the verb sharing as sharing informa-
tion with clients denotes an interaction.
Self-determination theory partially explains this. As noted in Chapter
2, the theory states that people need to have recognition of their compe-
tence, autonomy, and relatedness to thrive. Competence, in educating or
sharing information, is the understanding that your clients already know a
lot, at least about themselves and maybe the topic under discussion. Auton-
omy is the need to make decisions about whether to receive the information
or how to use it, and relatedness is having it presented in a context where
there is a relationship that includes a respectful, nonjudgmental environ-
ment (Miller & Rollnick, 2013; Ryan & Deci, 2017).
So how do you educate or share information with clients and be con-
sistent with the spirit of MI? Miller and Rollnick (2013) suggest the use of
what they term E-P-E, or elicit–provide–elicit. Look back at the vignette
in the previous chapter. How did the social worker provide information
about her role and the school policy on addressing bullying? She did so by
first eliciting or asking permission to ask a question (respecting autonomy)
and then asked the parents what they knew about school social workers
(respecting competence); she then provided information. Her second elicit-
ing question came after she provided information about the school policy
122 ELEMENTS OF MI

on bullying and her role, by asking the parents, “What do you think you
will do?”
If you want to explore what a client already knows about a topic or
provide information, you might first ask permission to raise the topic, par-
ticularly if it is a change in direction of the conversation. Usually permis-
sion is granted, but not always. If clients say no, that needs to be respected
and followed. Clients might have already asked for information, in which
case permission has been implicitly granted, or you have already been dis-
cussing a topic. The elicit or E question is something like “Tell me what
you know about . . . ?” or “What aspect of . . . would you like information
about?” This kind of response honors what clients already know as well
as helps us assess where there might be gaps in information or incorrect
information (Miller & Rollnick, 2013). This strategy is also collaborative
in that it is clients sharing what they know before we share.
For P, provide, it is helpful to continue to respect autonomy by again
asking permission to share a bit of information or even prefacing it with a
statement such as “I am not sure if this is something that will be helpful,
and feel free to disregard it,” and then provide the information. This later
statement allows clients the freedom to disagree with the information or
to determine whether it is useful to them (Schumacher & Madson, 2015).
Whatever information is shared should be clear, jargon-free, and in small
doses to allow clients time to think over what it might mean to them (Miller
& Rollnick, 2013). This time can be also be used to share concerns, as
discussed below, if clients are making decisions that put themselves at risk:
“I am very concerned that you are practicing unsafe sex.” Typically, you
do not share your feelings with clients but sometimes the moment might be
right for this to occur (Rosengren, 2018).
In the final E, elicit, you use open questions to ask clients what they
think of the information, or what aspects, if any, make sense to them, or
what decisions they may make based on the information. Use reflections to
follow up to demonstrate, nonjudgmentally, your understanding of their
understanding. This also allows clients to hear themselves think out loud
again (see discussion of self-perception theory in Chapter 2).
So what does this look like in practice? I was in a meeting once, with
county child welfare directors, where one director said, “I wish my social
workers knew how to talk about pregnancy prevention with their foster
youth.” Subsequent discussion in the meeting identified that social workers
don’t necessarily have all the information, that is, up-to-date knowledge on
birth control methods, and also that there was a discomfort in discussing
it, thinking it was beyond their scope of practice. This led me to thinking of
how this could be done using the E-P-E format. Firstly, social workers can’t
be experts on all kinds of topics, so the question in my mind was, how do
we have the needed information at our fingertips? In other settings, such
 Sharing Information and Advice 123

as mental health, social workers would already know a lot about depres-
sion coping skills or in a health setting, such as a kidney dialysis clinic, the
social worker might know a lot about renal failure issues and management.
However, medical information, such as pregnancy prevention methods, is
more out of the realm of typical child welfare work. One idea to help child
welfare workers was to have a pamphlet that summarized birth control
information that included abstinence. Now, how to bring up the topic and
discuss it with clients?
While MI and pregnancy prevention in teens has been studied (Bar-
net, Liu, DeVoe, Duggan, Gold, & Pecukonis, 2009; Meckstroth & Berger,
2014; Stevens, Lutz, Osuagwu, Rotz, & Goesling 2017), it has all been in
the context of preventing a second pregnancy, not preventing a first one.
The next step was to think about how E-P-E could be used. It could provide
a framework for the social worker to get past her own discomfort as well as
share accurate information with the client in a nonjudgmental manner. The
client in this scenario is a 16-year-old female in foster care. (SW = social
worker; C = client.)

SW: I am wondering if I could ask you a personal question? (Yes is

indicated.) Do you plan on getting pregnant in the next year?
C: What? How could you ask me that! Of course not!
SW: That’s good to hear. This may or may not be useful to you, that’s
for you to decide, but I was wondering if you would be interested
in hearing a bit about birth control methods. I know this is a very
personal decision and not an easy discussion.
C: I know a lot already, it’s OK.
SW: You already have information and don’t need any more.
C: Well, my friends tell me . . . [some misinformation about birth
control] and they say . . . [better information about birth control]
and I saw on Facebook that you can’t get pregnant when . . . [bad
information].
SW: You seem to know a lot and you are mostly accurate. It’s hard to
know everything, as there are many different kinds of methods.
That’s why I work off of this pamphlet—I can’t remember it all!
You can have it, by the way. You can either just take it or we could
spend a few minutes together discussing it. Would it be OK if we
looked at this information together? (Yes is indicated; they review
what is written on the pamphlet.) Now that you have looked at all
these methods, if you were to pick any, and I am not saying you
are sexually active, but if you were, what might be the best one for
you? What might be the pros and cons of such a choice?
124 ELEMENTS OF MI

C: Well I am not sexually active but if I wanted to be, I would prob-

ably pick . . . because . . .
SW: [reflecting her response.] How might I be of help to you if you
were to want to use this method?
C: Well maybe you could take me . . .

Pregnancy prevention in adolescents is a difficult topic. Teens in foster

care are at higher risk for pregnancy as compared to their counterparts
(Shaw, Barth, Svoboda, & Shaikh, 2010), so these can be important dis-
cussions. The question asked by the social worker about any plans to get
pregnant in the next year is a screening question advocated by OneKey-
Question (https://powertodecide.org/one-key-question). Asking it allows
the social worker to discuss pregnancy prevention, and allows women
and teens to take control of their reproductive health. The target behav-
ior would be picking and using a prevention method, if the client were to
become sexually active. The social worker used the E-P-E format to pro-
vide information about birth control and to discuss it in more detail with
the client, in an objective manner. The social worker emphasized that it
was up to the teen to decide what to do, if anything, with the information.
Of course, the target behavior is pregnancy prevention, but in the end,
teens (and adults!) make their own decisions either way. The discussion of
the pros and cons of each method is appropriate since the social worker
is in equipoise; only the client can make the decision about what method,
if any, is best for her. If the social worker wanted, she could pursue the
conversation to ask why the teen is staying abstinent and what the benefits
of that are for her.

Sharing a Concern

I once had a teen client tell me she knew she wouldn’t get pregnant because
someone told her to stand up after sex and that would work. Even when
you provide accurate information, sometimes clients don’t want to hear it,
they aren’t interested, or you are competing with teen friends who know
best. It can cause reactance and make you want to argue or plead your
case, and then clients push back and dig in even harder. How can you be
autonomy-supportive when the information you provide is not accepted or
when you have a concern about your clients’ decisions?
An MI-consistent approach is to do something familiar: ask permis-
sion. This could be “Would it be OK with you if I shared my thoughts on
that?” If the client says no, then respect that: “Maybe some other time
then.” Leave the door open. Typically, though, people are curious and open
 Sharing Information and Advice 125

if they have been treated in a respectful manner and have nothing to fear
by asking for our thoughts. You provide your thoughts or concerns, and
then elicit clients’ responses or their perspectives on the information, while
assuring them that the decisions are ultimately theirs to make (Rosengren,
2018). Trying to persuade them to do what you think is the right thing usu-
ally only produces discord.
Teen clients in the child welfare system or clients in probation settings
may be uncertain as to what to share with their social worker/probation
officer and thus may not give complete information. Schumacher and Mad-
son (2015) as well as Stinson and Clark (2017) both address this issue and
indicate that those who have dual roles (i.e., involved as representatives of
court systems as well as client advocates) should discuss these roles along
with the implications with their clients at initial client meetings. This sup-
ports clients’ autonomy (and they may choose to hold back some informa-
tion), but can also enhance the overall communication and relationship.
What if a teen, in the above example, blurts out that she is having sex with
a 25-year-old boyfriend? Depending on state law, the social worker would
have to share her concern about that with the client along with the legal
ramifications. The teen may be very angry if the boyfriend is arrested and
the social worker could respond to it using discord communication strate-
gies (see Chapter 6).

Sharing Advice in an MI Style

What if the teen were to say to the social worker, “I have a boyfriend [same
age] and we are having sex and I can’t decide which method is best for me!
What do you think I should do?” Oh, how you might love to answer that
question! You could give your opinion—she asked for it, right? Most social
workers have their ideas and they would be from the framework of (most
likely) middle class, educated, older, a certain religious preference, perhaps
their own trauma history, maybe different race, maybe no personal foster
care experience, maybe access to a private Ob-Gyn, access to reliable trans-
portation, access to a bank account . . . the list could go on. The point is,
you are not in the best position to make decisions for your clients. Even if
reactance theory explained why teens do differently from whatever their
social worker may suggest, the contexts of their lives are so different from
their social workers’.
This is an extra-credit test question I use every semester in my MI
classes: “Your client says, ‘I don’t know what to do, what do you think
I should do?’ What is your response?” The correct answer or a variation
of it is: “What do you think you should do?” You should first exhaust
whatever ideas the client may have since clients know themselves and have
126 ELEMENTS OF MI

the best information. If they run out of ideas, seemed stumped, or press
you for advice, an autonomous-supportive way of doing so is to provide
options, perhaps in the context of what some of your other clients have
done: “Maybe none of these will work for you, but some of my clients
chose to do X, others do Y, and another few do Z. Which, if any, makes
sense to you? Or maybe you have another idea?” Both social workers and
clients can generate ideas. As noted previously in this book, sometimes cli-
ents come up with ideas that you would never have thought about. In MI,
this is called providing a menu of options (Miller & Rollnick, 2013) and it
is examined more thoroughly in Chapter 8, on the Planning process.

Sharing Information and Advice in a Brief Intervention: SBIRT

Screening, brief intervention, and referral to treatment, or SBIRT (pro-

nounced “ess-birt”), is an evidence-based practice that follows the guide-
lines discussed above regarding sharing information and advice in an MI-
consistent manner. Originally developed as SBI in the early 1980s, the
intervention was a response to a call by the World Health Organization
for the development of a model that targets those who are not necessarily
dependent on alcohol and other substances, but have hazardous drinking/
drug use that could lead in that direction (Babor, Del Boca, & Bray, 2017).
SAMHSA put out an initial call for grants to research what became known
as SBIRT with two other funding cycles since then (Babor et al., 2017).
Since this initial funding, over 2 million people in the United States have
been screened for harmful alcohol and drug use (Bray, Del Boca, McRee,
Hayashi, & Babor, 2017). The outcome research on SBIRT has been mixed
regarding decreasing heavy alcohol use as well as illicit drug use (Bray et
al., 2017; Glass, Hamilton, Powell, Perron, & Ilgen, 2015).
SBIRT was developed as a public health intervention to be used in
opportunistic settings (a variety of service settings) where there are large
numbers of clients or patients who could be screened: emergency depart-
ments, primary care clinics, prenatal clinics, schools, community centers,
and college health centers (Bray et al., 2017; Hostage, Brock, Craig, &
Sepulveda, 2018; Hohman et al., 2018). Typically, the screening is universal
in that it is given to everyone (who is able) who presents in one of these set-
tings. The screening may be conducted by health educators, social workers,
nurses, physicians, or peer outreach specialists (Babor et al., 2017; Ser-
rano et al., 2017). Pharmacists are exploring their own use of SBIRT for
opioid misuse (Cochran et al., 2016). The session can be brief, around 15
minutes or so, or occur over several meetings, as has been implemented in
schools. The purpose is to raise patients’ awareness of their drinking/drug
use by sharing screening assessment scores and safe drinking limits, moti-
 Sharing Information and Advice 127

vate them to reduce their drinking, and collaboratively develop a plan to

accomplish this. It should be noted that SBIRT is billable under Medicaid
and Medicare (Cochran & Field, 2013).
As for the steps of SBIRT, usually patients are prescreened, to see if
they drink or use substances, and if yes, are asked to complete a stan-
dardized assessment measure of alcohol or drug use, either in a pen-and-
paper self-report or in an interview that may be computer-based. Screening
measures ideally are brief and easy to score, due to the limited time for
the SBIRT interview in most settings (Mitchell, Gryczynski, O’Grady, &
Schwartz, 2013). Based on the results of the scoring of the measure (cur-
rently the Alcohol, Smoking and Substance Involvement Screening Test
[ASSIST; Humeniuk et al., 2008]), patients are provided feedback about
their scores. Many SBIRT programs use tablet computers that not only
score the screening measure, but provide guidelines/decision trees for the
person conducting the interview. Once computers have scored the assess-
ment measure, results are categorized as low risk, at risk, or high risk.
Those in the low-risk category receive acknowledgement of this along with
recommendations to continue at this low level of drinking. Those who
are in the at-risk or high-risk categories receive a brief intervention that
includes sharing information about risks associated with their level of use
and safe use guidelines. Patients are asked if they would be willing to cut
back and are given a menu of options on how this might be accomplished
along with strategizing their own methods. Change rulers are sometimes
incorporated. Patients are asked to create a plan and materials with the
plan are sent home with them (Vendetti, McRee, & Del Boca, 2017; Wood-
ruff, Eisenberg, McCabe, Clapp, & Hohman, 2013). Patients who score
as high risk on the ASSIST are referred to a community-based treatment
program as well.
The score adherence checklist for SBIRT (Vendetti et al., 2017, p. 36)
provides an outline for the process. MI is very much integrated into SBIRT
and the skills and components of MI that are to be included are:

• Express empathy
• Reduce resistance (discord)
• Develop discrepancy
• Support self-efficacy
• Utilize open-ended questions
• Utilize reflective listening
• Utilize summary reflections
• Generate change talk
• Avoid lecturing, warning, convincing
• Ask permission to educate or suggest advice
• Close with a summary
128 ELEMENTS OF MI

While there is a framework for SBIRT, along with the MI components,

there is some flexibility in how it is implemented, based on patient and set-
ting characteristics (Del Boca, McRee, Vendetti, & Damon, 2017). It has
been adapted for the military as well as for specific cultural populations
(Sahker, Acion, & Arndt, 2016). For instance, innovative work by Field,
Oviedo Ramirez, Juarez, and Castro (2019) used a list of cultural values
generated from a focus group in a handout. This was used for discussion
regarding heavy alcohol use with Spanish-speaking Latinx patients in an
emergency department. SBIRT models have been applied to interventions
in other areas including smoking, depression, and intimate partner vio-
lence (Gilbert et al., 2015). Some models use technology, where the inter-
view with feedback and other aspects of the intervention are completely
computer-based (Resko et al., 2017).
The American Academy of Pediatrics has recommended SBIRT for
alcohol and drug use for adolescents and has provided clinical guidelines
for physicians (Levy, Williams, & Committee on Substance Use Preven-
tion, 2016). It has been adapted by using screening tools that are appropri-
ate for adolescents (Mitchell et al., 2013) as well as guidelines for the brief
intervention that suggest that advice be given for no use/drinking (Levy et
al., 2016). One SBIRT model for adolescents, conducted in an emergency
department, focused on alcohol use as well as fighting and weapon carry-
ing. It was delivered in both an in-person and computer-based interactive
formats. Along with personalized feedback, the model utilized a decisional
balance. Outcome research found that both models of the intervention
reduced alcohol consequences at 6 months post-intervention, but these
were not maintained at the 1-year follow-up. The program, SafERteens,
did reduce violent behaviors, for those who received the in-person inter-
view (Cunningham et al., 2012; Resko et al., 2017). A recent review of
the randomized controlled trials of SBIRT with adolescents found mixed
outcomes but that overall, brief interventions show promise with this popu-
lation (Mitchell et al., 2013).

SBIRT and Social Work

Based on the positive outcome studies of SBIRT, with the knowledge that
patients/clients seen in various social service settings are at risk for drink-
ing and substance use problems, an initiative by SAMHSA as well as pri-
vate funders has helped to move SBIRT training into the social work cur-
riculum, at both the bachelor’s and the master’s levels (Sacco et al., 2017).
The CSWE has partnered with SAMHSA to provide a Web-based semi-
nar on SBIRT and social work education along with a webpage of SBIRT
resources (www.cswe.org/Centers-Initiatives/Initiatives/Social-Work-and-
 Sharing Information and Advice 129

Integrated-Behavioral-Healthcare-P/SBIRT-Resources). SBIRT curriculum

typically has been infused in social work practice courses along with skills-
based work in field seminars and settings or in interprofessional classroom
settings with nursing and medical students (Carlson et al., 2017; Gotham,
Knopf-Amelung, Krom, Stilen, & Kohnle, 2015; van Eeghen et al., 2019).
Trainings typically include role plays, standardized clients (actors play-
ing defined roles), and computer-based interactive methods for simulation
(Boyle & Pham, 2019; Resko et al., 2017). Field instructors have been
included in training as well and are encouraged to implement SBIRT in
their respective agencies (Egizio, Smith, Bennett, Campbell, & Windsor,
2019; Putney, O’Brien, Collin, & Levine, 2017). Outcomes have mainly
reported increased knowledge, assessment skills, motivational interviewing
skills, and more positive attitudes of students toward identifying and inter-
vening with alcohol and substance misuse (Carlson et al., 2017; Egizio et
al., 2019; Gotham et al., 2015; Putney et al., 2017; Sacco et al., 2017; van
Eeghen et al., 2019).

SBIRT and Harm Reduction

SBIRT is essentially a harm-reduction approach, in that the goals are

usually to reduce and not necessarily eliminate alcohol or drug use or
use-supporting behaviors. SBIRT has been used to increase safety around
injection use (Bertrand et al., 2015), to reduce risk for opioid overdose
(Bohnert at al., 2016), and to encourage buprenorphine use (opioid sub-
stitution) with a referral to treatment (D’Onofrio et al., 2015). Despite the
congruency of social work values and those of harm reduction—that is, cli-
ent self-determination and client goal setting—harm reduction as a concept
or therapeutic goal can still be somewhat difficult for some social workers to
embrace (Bride, Abraham, Kintzle, & Roman, 2013; Christie et al., 2019;
Fillmore & Hohman, 2015; Vakharia & Little, 2017). The prevalence of
the disease model of addiction that specifies abstinence as well as moral
perspectives requires a paradigm shift in thinking as well as understanding
of the research that supports harm reduction. Beyond that, putting harm
reduction into action is “a complicated combination of accurate education,
different therapeutic models, medications, skill building, nutrition, support
from family and concerned others, and more” (Stout, 2009, p. 8).
A definition of harm reduction is “an approach to working with drug
users that aims to reduce drug-related harm to individuals, their families,
and communities” (Denning & Little, 2012, p. 6). Initially developed to
address injection drug use in Europe, and then the HIV epidemic, harm-
reduction efforts in the area of safe injection practices and needle exchange
programs have been found to decrease HIV spread (Fernandes et al., 2017).
130 ELEMENTS OF MI

Currently there is concern about hepatitis C virus spread as well, which is

increasing in prevalence among people who inject drugs (Davis et al., 2019).
Harm-reduction programs have been found to be especially effective
when psychosocial interventions (such as SBIRT) are included, as com-
pared to simply providing information/education only (Gilchrist et al.,
2017). In other words, you ask about clients’ goals and knowledge (elicit),
provide the information they want, and then elicit their thoughts about
that information—perhaps the magic comes in the conversation that is
done in the MI spirit. All harm-reduction providers work to establish ther-
apeutic relationships that leave the door open if, down the road, clients
decide to ask for further help or treatment.

Vignette and Dialogue Example:

Sharing Information and Advice

Tony is a 19-year-old White male who resides in a small city in the Mid-
west. He was raised by his mother until she was killed when he was 12.
Subsequently he was sent to live with relatives who eventually asked that he
be removed from their care due to his behavior problems and their worry
about their own small children. Tony spent the next 4 years in the foster
care system. When he was 17, he was arrested for possession of drugs (opi-
oids) and was placed under supervision of the juvenile probation system
in a group home. At age 18 he was released from supervision. He finished
high school and has worked various jobs in the restaurant industry, floating
from friend to friend for housing. He periodically stops by a community
drop-in center that was established specifically to support former foster
youth. Mainly Tony utilizes the program to socialize, but today he has
asked to speak to one of the social workers whom he has met in the past,
Marissa. (SW = social worker; C = client; [MI skills/OARS are in brackets];
change talk is underlined.)

C: Hi, Marissa, would it be ok to talk to you for a little bit?

SW: Sure, Tony, come on into my office. (They go in.) How are you
today?
C: Uh, not too good. . . . I just had a really freaky thing happen and I
don’t know what to do about it . . .
SW: You’re upset about something that just happened. [simple reflec-
tion]
C: Yeah and it has me pretty freaked out and I don’t know what to
do. Not that I need to do anything, but I am just having a hard
time.
 Sharing Information and Advice 131

I always gravitated toward the philosophy of harm reduction. I was drawn in by the
pragmatic approach to reducing the potential harms of risky behaviors coupled with
a profound respect for the human dignity of people who use drugs. I spent several
years learning about harm-reduction policies before eventually learning how to
translate harm-reduction principles into social work practice.
I ended up putting harm reduction into practice as an outreach worker in an
organization providing community-based mental health and housing services. I
learned that the potential of harm reduction expanded far beyond reducing levels of
drug use, using sterile syringes to inject drugs, or even carrying naloxone to reverse
opioid overdoses.
Our participants, and all of us, were practicing harm reduction every day. When
our participants made budgeting decisions about paying rent before buying drugs,
they were practicing harm reduction. When participants who were not interested in
taking psychotropic medication found other strategies to manage the symptoms of
their mental illness, they were practicing harm reduction. When participants offered
emotional support to their peers in group counseling sessions, they were practicing
harm reduction. Harm reduction is really about making any positive change, as Dan
Bigg of the Chicago Recovery Alliance frequently pointed out.
As I moved from direct service into staff development, I found that social
workers and service providers intellectually understood that people could make
positive changes in their lives, but struggled with how to implement this knowledge.
The response to learning about harm reduction was frequently “I get harm
reduction, but what do I do?”
The challenge is how to help participants make the incremental changes that
reduce harm and improve quality of life. Too many of our service systems are geared
around absolute changes—you’re homeless, get housed; you have a mental illness,
take medicine; you use drugs, stop. These solutions fail to acknowledge the world
of possibilities between the status quo and an ultimate goal. This way of thinking
doesn’t accurately reflect the way that most people make changes in their lives.
MI answers the question of how to help people navigate their ambivalence and
pursue positive changes related to risky behaviors. Whereas harm reduction offers
solutions for what to do, MI provides guidance on how to do it. As I’ve learned
over the years, there is a great deal of intersection between MI and harm reduction.
Both approaches are fundamentally based in a respect for human dignity, an
acknowledgment of people’s interest in and capacity for self-improvement, and the
promotion of relationship building as an essential part of positive change. Wedding
these two approaches offers a pathway to supporting people’s pursuit of positive
changes no matter what they are facing or where they are in the change process.

                         James Kowalsky, AM

                        Project director
                        Chicago, Illinois
132 ELEMENTS OF MI

SW: If you want, Tony, tell me what happened. And before you do, is it
ok to give you a little information? Anything we talk about is con-
fidential unless it involves your thinking about hurting yourself or
someone else. Do you still want to talk? [autonomy support; open
question; sharing information]
C: Yes, yes, that’s not it, not at all. Well, I was living with this guy
Dave. He worked with me and he knew that I was between places
and he offered to let me sleep on his couch. We’ve been using
together a bit so I knew he was into shooting up. I went to work
yesterday and he never came in like he was supposed to. They
sent me home to find him and he had OD’d in his bathroom and
was leaning against the door. I didn’t know what to do ’cause I
couldn’t open it. I cleaned out my drugs and went back to work
and told my boss. He called the cops and we both went back to
the apartment. They questioned me and they saw that I had noth-
ing to do with it. My other friend, Sam, said I could come to his
place so that’s not a problem but I’m just so freaked out. I never
saw a dead body before. I never even saw my mother after she was
killed. They kept me away.
SW: You’ve been through not one but two terrifying experiences. Being
the one to find a body is very, very difficult, especially when he
died in those circumstances. [complex reflection]
C: Yeah, well, that is what has me so freaked out. That could easily
have been me! You probably have figured out that I shoot up, too.
I know there are problems with that and I manage it the best I
can but still . . . to have that happen to someone who is older and
knows what he is doing.
SW: It’s all been a big shock to you. [simple reflection]
C: Yeah, that’s for sure.
SW: And you’re thinking “That could have been me” and that is fright-
ening, too. [complex reflection]
C: Yes, I mean, I’m careful but still . . .
SW: You’ve got a lot of different things on your mind right now. Tony,
how would you like to use this time together? I’m curious about
what you do to stay safe and avoid overdosing but there are all
kinds of things we could talk about. We could talk about what
just happened, or we could talk about ways to keep yourself safe
when you inject, or ways to prevent overdosing. Or we could talk
about getting medication to get you off heroin or even about get-
ting into more stable housing or drug treatment. Those are just
some ideas. What seems to be most important to you right now?
[simple reflection; menu of options; open question]
 Sharing Information and Advice 133

C: I don’t know, I just was so freaked out that I had to talk to someone
and I can’t stop worrying about how that could have easily been
me.
SW: So it might be helpful to talk about what you can do to avoid over-
dosing. [simple reflection]
C: Well, I think I know what I am doing but maybe you have some
ideas, too.
SW: Yes, it’s important to have some ways to keep yourself safe. I do
have some information on that. Here’s a handout I keep on hand
that is about ways to stay safe when you inject drugs. Would you
be willing to take a look at this and tell me what you already
know? You are probably already doing a lot of these steps and
I don’t want to bore you with stuff you already know. [simple
reflection; sharing information; closed question; affirmation]
C: (Reads over it.) “Always use with others”: Well, one thing I know
is that Dave made a mistake using alone like that. If I had been
there I could have at least called an ambulance. I know there is
that overdose-reverse drug, what’s it called, but I don’t carry any
of that. Maybe I should. I never use alone so there would be peo-
ple around who could use it on me.
SW: That’s great to hear and smart. The overdose-reversal drug is
called naloxone and it could help you save your life or someone
else’s life. Your friends could use it on you once they have training,
which goes pretty quickly. Would training in that be something
you might be interested in? We do it here. (Client shakes head
yes.) What else do you already know or do? [affirmation; sharing
information; closed question; open question]
C: I pretty much always buy my stuff from the same person. So I know
what I am getting. But still it could be a problem if it is cut with
something different.
SW: Great! You’re absolutely right; another way to use more safely is
to buy from the same dealer whenever possible. Can I ask you a
question? Have you ever used fentanyl test strips? (Client shakes
his head no.) Would it be OK if I explained them? We have some
here that you can have if you want. You put a strip in your her-
oin to make sure that it hasn’t been cut with fentanyl, which you
know could be deadly. Unfortunately, that is becoming more com-
mon. Would this possibly be something you might be interested
in? [simple reflection of change talk; closed question; sharing
information; closed question]
C: Sure, I’ve never seen them, but I am pretty sure fentanyl is not
a problem. But it would probably be a good idea to have them.
134 ELEMENTS OF MI

Thanks. (Looks at pamphlet.) It says here that if the heroin tests

positive for fentanyl, that I should either not use or just use a small
tester shot. I’d probably do the tester shot.
SW: Yes, it’s recommended that you not use your heroin if it has fen-
tanyl in it and if that isn’t an option, the tester shot is a way to
make sure it isn’t cut too much.
C: (Looks at pamphlet again.) I see here that it says to try to switch to
snorting or smoking rather than injecting. Nah. That’s not some-
thing I would want to do.
SW: I appreciate your honesty. You definitely know yourself best. What
else on this list might work for you, if you aren’t doing it already?
[affirmation; simple reflection; open question]
C: Maybe one of these days I could look into getting the medication,
you know, methadone or this Suboxone. But not now.
SW: This isn’t right for you now but using medication might be of
help down the road. What do you know about it, if I might ask?
[simple reflection; open question]
C: Well, I know I could go to one of those clinics where they have
methadone or Suboxone if I decide to try to get off heroin. But I’m
not really ready to think about that right now.
SW: This isn’t something for you right now, but maybe down the road.
So let me summarize what we’ve talked about so far. You have
had a frightening experience after finding your friend overdosed
and then having to deal with the police. You have some concerns
about not overdosing yourself and you’re already doing some
things to keep yourself safe like knowing it’s important to use
with other people, to carry naloxone and know how to use it, to
always buy your drugs from a trusted source, to still check it with
the fentanyl test strips we will give you, and to either not use it
or use a tester shot if it is cut with fentanyl since it’s so deadly. Is
that about everything or what would you like to add? [summary;
closed question; open question]
C: No that’s good, you’ve helped me to calm down. I will get the nal-
oxone training and take those test strips if you could give me the
info. I’ll keep this pamphlet and think about maybe the medica-
tion stuff. I’m kind of getting tired of this life and I don’t want it
to get tired of me, if you know what I mean.
SW: You want to keep yourself safer when you use drugs and are will-
ing to do some things to achieve that. It’s not easy with all that
you have been through and yet you are a survivor. We’re here
any time, Tony. Would you be interested in meeting our naloxone
 Sharing Information and Advice 135

trainer now so that you can leave with naloxone today? [complex
reflection; affirmation; sharing information; closed question]
C: Yes, and thanks for all this.

In rural areas in middle America, opioid use (both pills and heroin)
and fatal overdose have become a public health crisis in the past few years,
but this crisis is by no means solely located there (Davis et al., 2019). As the
government moves to strongly regulate access to opioid medications, those
who have been using them for nonmedical purposes are increasingly turn-
ing to heroin use, thus increasing the rise of injection drug use along with
the spread of hepatitis C (HCV) due to the sharing of needles (Davis et al.,
2019; Zibbell et al., 2018). HCV is a silent disease with no symptoms until
it eventually causes renal failure and early death (Molnar et al., 2015). As
noted, overdose is a serious problem along with other infections caused by
needle use. Heroin cut with non-pharmaceutical-grade fentanyl, a manu-
factured and extremely potent opioid, has become more widespread and
caused over 30,000 overdose deaths in 2018 (Pardo et al., 2019).
This was not a typical SBIRT intervention in that Tony was the one
to approach the social worker and no predetermined target behavior was
identified by her. She had, however, been trained in SBIRT and utilized its
framework and MI skills. She listened in order to engage him, and then used
a menu of options to elicit from him what area they might focus on. Tony
selected overdose prevention, which became the target behavior. Marissa,
the social worker, proceeded into a brief intervention by giving a printed
pamphlet to Tony and asking him to discuss how he personally stayed safe
from overdose, based on the methods that were provided. She shared infor-
mation with him when he was unclear and also offered him some resources.
Marissa kept the conversation brief, but they were able to cover four safety
methods. She did not need to formally elicit from Tony his thoughts on the
various safety methods as well as his next steps, as he voluntarily shared
them as they went along. She pulled it all together with a summary, which
elicited even more change talk from Tony. Marissa did not provide him any
advice as he had not asked for it, nor did it seem necessary—the pamphlet
was doing it for her. Her use of OARS skills related to the pamphlet’s con-
tent led Tony to develop his own change plan as well as to muse that maybe
he would look into medication-assisted treatment. By engaging with Tony
with compassion and support after he opened up about his risky behav-
ior, the social worker was able to provide helpful information and made it
more likely that he would engage with her or another service provider in the
future.
Harm reduction is not always an easy concept, as you want the best for
your clients, which can include moving away from a drug-oriented lifestyle.
136 ELEMENTS OF MI

However, harm reduction set in the context of a relationship and infor-

mation sharing can encourage movement in a positive direction, however
small. Bill Miller (2009) put it well:

It has always seemed sensible to me that steps in the right direction is what
one would want to do because human beings aren’t perfect . . . and most
people most of the time don’t make changes in an absolute kind of way.
We’re not all quantum changers; most of us most of the time change a
little bit at a time. Indeed big commitments tend to happen in small steps
at a time. (pp. 67–68)

Final Thoughts

Social workers often take on the role of educator in the various settings
where they work. Having the E-P-E format provides a framework to make
the sharing of information interactive and collaborative as well as consis-
tent with the spirit of MI. E-P-E can be used in formal educational settings
as well, as is noted in Chapter 12. SBIRT is an evidence-based practice that
is an example of sharing information in an MI style but also seeking clients’
thoughts on the information. SBIRT has been modified for specific groups
of clients based on culture or age group and has been extended beyond
alcohol and drug use to address other harmful behaviors. Future research
and practice could focus on its use in agency and nonprofit settings such as
in the case vignette.

EPAS Discussion Questions

EPAS 2: Engage Diversity and Difference in Practice

 Present themselves as learners and engage clients and constituencies as
experts on their own experiences.

EPAS 4: Engage in Practice-Informed Research and Research-Informed Practice

 Use and translate research evidence to inform and improve practice, policy,
and service delivery.

EPAS 8: Intervene with Individuals, Families, Groups, Organizations, and

Communities
 Critically choose and implement interventions to achieve practice goals
and enhance capacities of clients and constituencies.
 Sharing Information and Advice 137

1. How does the E-P-E model maintain the focus on clients being the
experts on themselves?
2. What is your role now as an educator? How might you
incorporate the E-P-E model in your work?
3. How were Tony’s capacities enhanced in the case example? What
is your reaction to the overall discussion he had with his social
worker?
 C hapte r 8

Planning
Determining the Path Forward

EPAS 7: Assess Individuals, Families, Groups, Organizations, and

Communities
 Develop mutually agreed upon intervention goals and objectives
based on the critical assessment of strengths, needs, and
challenges with clients and constituencies.
EPAS 8: Intervene with Individuals, Families, Groups, Organizations,
and Communities
 Critically choose and implement interventions to achieve practice
goals and enhance capacities of clients and constituencies.
(CSWE, 2015, p. 9)

A funny thing happened on the way to the RCT (randomized controlled

trial, or experimental design study) . . . or perhaps it is more correct to say
that a funny thing happened during the RCT: some of the study subjects
rebelled.
As you probably remember from research class, RCTs follow a strict
protocol to make sure everyone in the intervention group is getting the
same intervention. Usually the intervention is specified in a manual that
therapists are to follow. Based on the manualized treatment for an MI
brief intervention for alcohol misuse, clients were taken through Engag-
ing, Focusing, assessment feedback, Evoking, and then, Planning. But not
everyone was ready to make a plan and some rebelled by returning to sus-

138
 Planning 139

tain talk or weak change talk (Amrhein et al., 2003). Another study found
that clients who knew they had problems with alcohol wanted to move
quickly into Planning or making changes, and felt constrained by the thera-
pists’ insistence on following the manual’s steps and didn’t want to spend
time in the Evoking step (Project MATCH Research Group, 1998). Because
of these results from these studies and others, some subsequent studies of
MI did not use a manual with prescribed steps and a meta-analysis of these
studies found even greater effect sizes in outcomes (Hettema et al., 2005).
So what does this tell us?
Social workers often work with clients who are interested in moving
forward regarding a problem. Examples could be someone seeking help
after the death of a spouse, having a concern about a child who is having
problems in school or work-related issues such as a difficult boss, and mak-
ing decisions regarding major life changes. These clients come to us with
motivation. They are ready to plan and move into action. They want to
work on how to do it (Resnicow et al., 2012).
Other clients are ambivalent or perhaps have little to no ambivalence
about a concern, which is often one that someone else has raised for them.
These tend to be clients who are involuntary in one way or another. And
usually the more ambivalent (and upset and angry) clients are, the more
MI tends to be effective (Project MATCH Research Group, 1998). These
are the clients you need to engage, develop a focus with, and then evoke
the why of the problem (Resnicow et al., 2012). You may not ever reach a
Planning process with them but that is okay. The Evoking process allows
people to hear themselves, and hopefully most of what they hear is their
own change talk. This can plant a seed for later germination. Miller and
Rollnick (2013) note that sometimes just listening to oneself (as a client)
in an atmosphere of curiosity, respect, acceptance, and compassion from
someone else can be healing in and of itself.
Chapter 5 presented change talk and that it is categorized as either pre-
paratory change talk (desire, abilities, reasons, need, or DARN) or mobiliz-
ing change talk (commitment, activation, taking steps, or CAT). This all
means that the MI social worker stays attuned to clients throughout the
conversation, listening and reinforcing change talk and also paying atten-
tion to clients who seem to be moving from why (preparatory change talk)
to how (mobilizing change talk).

The Transition into the Planning Process

How do you know clients are moving into the Planning process, so you are
neither pushing them forward too quickly nor being too slow in respond-
ing to their desire to move ahead? Miller and Rollnick (2013) give some
140 ELEMENTS OF MI

tips. One tip is to notice the decrease in sustain talk and increase in change
talk. For example, my students turn in transcripts of their simulated client
MI interviews and are asked to highlight the sustain talk in pink and the
change talk in green. Visually, by the end of most of the interviews, the
pages are almost completely green. Look at the client examples in other
chapters, and see how much underlining there is by the end of the conversa-
tions, denoting change talk. When you are using MI in an interview, you
can feel this change in the type of language along with energy from clients
that they are moving in a positive direction. Clients may feel or seem more
settled, thoughtful, and hopeful (Rosengren, 2018).
Clients might start asking questions about change or musing on how
they might change, and what they might do. They start envisioning the
future with the change in place and how things could be. You can always
ask about this, too, to elicit change talk. Here is an example of something
to ask a client who is worried about his debt: “If you look down the road
from now, say in 5 years, and you have got yourself on a financial plan,
what do you think your life will be like?” Clients may also indicate resolve
to address their concern along with steps on how to do it, such as, “I have
got to get my spending under control now, and the first thing I will do is
cancel all of my credit cards.” If you are working with clients in other than
brief settings, they may return to you and tell you about what steps they
have already taken. Listen for the mobilizing change talk: commitment to
change (“I will do this,” or “I should do this,”), activation (“I’m willing to
look into what I need to do to cancel credit cards”), or taking steps (“I met
with a financial person at the bank and they helped me lay out a saving
plan”).
A note here on language: saying that I “might” do something is very
different from saying that I “will” do it. Both are types of change talk, but
obviously saying that one will do something is much stronger. You might be
disappointed when you hear weaker change talk, especially when you have
spent a lot of time evoking it and reflecting all the reasons the person, say,
thinks they need to reduce their spending. To hear, “I might do it” can be
discouraging after you have worked to evoke so much DARN change talk.
Miller and Rollnick (2013) remind us that weak change talk is still change
talk, and you can reinforce it but be careful of pushing for the stronger
change talk. People move at their own pace.
As you hear mostly change talk in your conversations, at some point it
helps to give a recapitulation summary of it all, to help clients hear them-
selves, again, in an organized manner (Miller & Rollnick, 2013). Highlight
their change talk. You can include a little of clients’ sustain talk but the
summary should focus on all the DARN language that you have heard.
This leads you then, after the summary, to ask a key question, something
along the lines of, “What do you think you might do next?” Use hypotheti-
 Planning 141

cal language so as not to put pressure on clients, as you don’t want to cause
them to rebel.
In a sense, you are testing the waters. Clients who are fully ready to
move into Planning may be full of ideas of what they could do or steps to
take, but this isn’t always typical. After you provide the summary, and ask
a key question, it is time to sit back and allow clients some space to think it
all through. It is natural to want to jump into Planning, but silence can be
helpful to slow you down as well as give clients time to really think (Miller
& Rollnick, 2013; Rosengren, 2018). If clients return to sustain talk at all,
then most likely they are not quite ready to move into Planning. It could
signal a confidence issue, that is, clients could feel that they don’t have
what it takes to make the change. If this occurs, using the change ruler or
evoking previous successful experiences/changes can be of help to increase
confidence by looking at how the same behaviors or characteristics could
be applied to the target behavior (Stinson & Clark, 2017). Affirmations—
but not cheerleading—of clients’ strengths based on observable behavior or
values can lend hope as well (Miller & Rollnick, 2013, p. 213).

Planning

Planning is a process. Once clients have made the decision to make a

change, you don’t check your MI skills and spirit at the door. You continue
to utilize them, being careful to keep the focus on clients’ ideas and ways
to address what they want to do. You want to be on guard against any
tendency to want to take over; in other words, beware the righting reflex!
As a process, Planning is collaborative in that you can share informa-
tion, or, with permission, provide advice. The first step is to confirm the
goal: “I want to get out of debt.” A goal should be broad, something that
is achievable, and something that our clients want (Matulich, 2013; Rosen-
gren, 2018). It is helpful if it is framed in the positive direction of a behavior
to achieve. For instance, you could encourage the client in this example to
think about rewording the goal: “I want to be financially solvent at the end
of each month.”
The second step is to brainstorm options of how to accomplish the
goal, with clients taking the lead on what they think will work for them. If
you do share ideas, you do it within a menu of options. Clients may discuss
the pros and cons of each method they have generated:

“I could cut up my credit cards, but that might hurt my credit score;
I could go to the bank and get advice on saving and direct deposit,
and maybe that way I wouldn’t even miss the money; I could just
not carry my credit cards and only spend the cash I have, except
142 ELEMENTS OF MI

who wants to walk around with cash; I could set a budget for dif-
ferent expenses and work to stay in it, although that sounds so
restrictive!”

Once clients settle on the steps they will take, it is also helpful to ask
for a commitment to a timeframe of when these will occur (Miller & Roll-
nick, 2013). If the mobilizing change talk is weak, as in “I might go to the
bank for a meeting,” you could ask, “What might it take to make this a real
possibility?” and then reflect their answers.
Interestingly, this type of decision making or collaboration around
generating methods to achieve a goal is becoming more prominent in the
medical field in a model called shared decision making (SDM; Légaré &
Witteman, 2013). The idea is for patients to make informed decisions
regarding medical treatment when there are different options to choose
from. It is the role of the physician to provide the research on the risks
and benefits on the various treatment methods (often visual aids or tools
are used as handouts) and to collaboratively, with the patient, determine
a course of action. In other words, SDM relies on the two experts in the
room (the patient and the doctor) along with the best available evidence.
The goal is to improve outcomes by matching choices to the values and
needs of patients. Elwyn and colleagues (2014) believe that MI is a good fit
with SDM in that practitioners can use MI to engage and evoke regarding
a specific medical goal that is behavioral (for instance, diabetes control)
and then utilize SDM to examine alternatives, reflect on them, and then
determine the next steps. Within SDM is what is called option talk and
decision talk, with the outcome being a decision (or decisions) (Elwyn et
al., 2014).
There have been only a few studies published regarding social work
and SDM specifically. Peterson (2012) proposed the use of SDM by medical
social workers in primary care settings, particularly as social workers value
self-determination and understand the various contexts and cultural histo-
ries within which clients/patients may frame their decisions. Lukens, Solo-
mon, and Sorenson (2013) used vignettes and other measures to determine
how mental health social workers approached various types of clients, along
with their willingness to use SDM for each vignette. The authors identified
that this client-centered, collaborative decision making was important in
the recovery movement and the self-determination orientation in mental
health treatment. The results of their study found that social workers were
open to SDM and were more likely to use it with clients who they felt were
less severe in their diagnoses. Clients who had depression or bipolar disor-
der with no evidence of intent to self-harm, no psychotic symptoms, and no
substance use issues, and who were adhering to treatment, were considered
good candidates for SDM. The social workers in the study, on the other
 Planning 143

hand, were less likely to utilize a collaborative approach with clients who
they assessed to be at greater risk.
These findings were similar to those in a study of child protection social
workers, some who knew MI (this study was not specifically about SDM),
but chose not to use MI with clients they determined as too risky. Some
of the social workers in the study became much more directive, advising,
and warning in their interactions (Wilkins & Whittaker, 2017). Why did
some of the social workers in the study utilize these non-MI communication
methods? Some were concerned about the risk to the child, others wanted to
focus more on the child’s needs and were suspicious of parents, and others
did not embrace the values of collaboration and self-determination (Wilkins
& Whittaker, 2017).
In both studies, it seems when social workers see greater risk or even lia-
bility, they are less likely to consider clients’ views and options. They are less
likely to trust that their clients can make sound decisions. Granted, working
with high-risk child welfare and mental health clients is a bit different from
the example given above, of a client who is drowning in debt, and these
are findings from only two studies. Whatever the setting, however, Planning
needs to be a collaborative process in order to be most effective. You want to
increase the likelihood that clients will follow through with what is on the
final plan (Joosten, de Jong, Oene, Sensky, & van der Staak, 2009).
Once clients have generated options or steps (perhaps with your help),
and have decided on the ones that they want to take, the next step is to
generate a list of who in clients’ lives may be most helpful or supportive
in making these changes as well as the kind of support that they want.
Sometimes telling a friend or family member about a decision or asking for
help can be role played as to how to follow through on these steps. Next,
Planning should include thinking about the barriers or challenges that cli-
ents may face and how they will overcome them (Miller & Rollnick, 2013).
The last step on a plan is to identify what it will look like when the plan is
working, almost as a way to self-evaluate what has been accomplished. In
some ways, this aspect of the discussion mirrors the preparatory, DARN-
CAT change talk.
It depends on the client and the situation as to whether having this in
writing is needed. Miller and Rollnick (2002, p. 137) suggest an outline
that could be used in a handout for clients to take home:

1. “The most important reasons why I want to make this change are
. . . ” [Social worker recapitulation summary beforehand can help
here.]
2. “My main goals for myself in making this change are . . . ”
3. “I plan to do these things in order to accomplish my goals: [specific
action/when?] . . . ”
144 ELEMENTS OF MI

4. “Other people who could help me with change in these ways: [person/
ways to help] . . . ”
5. “These are some possible obstacles to change, and how I could han-
dle them: [possible obstacle/how to respond . . . ”
6. I will know my plan is working when I see these results: . . . ”

What if clients come back to see you a week later and tell you that they
didn’t do their intended change plan? First of all, remember, life happens.
Emergencies or more pressing demands can take away time or motivation
from clients. Ambivalence resurfaces. In a nonjudgmental way, you might
explore what did or didn’t happen, how this particular barrier to change
might be addressed (based on clients’ ideas), and summarize the motiva-
tors again for changing. Sometimes barriers are things beyond clients’ con-
trol, such as a lack of transportation, figuring out how to juggle multiple
demands, agency services not available as indicated on the website, and the
like (Stinson & Clark, 2017). You can check with clients about the goal
and refocus or re-evoke as needed, revisit your discussion on barriers and
ideas of how to address them, or provide resources as you are able, such as
giving bus tokens. Remember, the four processes are not linear and can be
returned to as seems best (Miller & Rollnick, 2013).

Planning within the Context of a Larger Plan

Depending on the setting where you work, you may only see clients once
or twice, and each interaction usually has one specific focus (Schleider,
Dobias, Sung, & Mullarkey, 2019). Shorter-term settings, such as adult
protective services (APS), often require social workers to address multiple
needs perhaps over a month or less and then refer clients to community-
based programs for ongoing case management. Longer-term settings such
as mental health programs, child welfare, probation, or substance use dis-
order residential treatment most always involve treatment plans that con-
tain multiple goals. Usually treatment goals are based on structured assess-
ments as well as collaboration with clients in identifying priorities. Goals
may be addressed one at a time or several all at once (Tafrate, Mitchell,
& Simourd, 2018). Clients in these settings, especially probation or child
welfare, may have plans that are predetermined by judges or have condi-
tions from the courts (Stinson & Clark, 2017). Plans may also have to be
coordinated with those created by other treatment agencies, such as when
APS, probation, or child welfare refer to medical care, case management,
mental health/substance use programs, and the like.
In circumstances where there are predetermined plans, it is helpful to
give clients as much control over the situation as possible. In terms of goal
 Planning 145

setting, clients’ goals in involuntary settings may be along the lines of “get
you out of my life.” That’s a reasonable goal that you can acknowledge. You
may need to spend time reflecting their anger about losing autonomy over
daily aspects of their lives. After engaging clients and hopefully reducing
some discord, you can ask clients to think about how to frame a broad goal
that is in a positive direction. Of course, this is challenging and it may mean
asking them, given the situation, how you can best be of help or what might
be important to work on. The ideas may not come quickly, but once stated
can give you some clues as to what a broad goal might be, which most likely
will need to be refashioned into a positive statement. For instance, “I need
a job” or “I need to fix things with my family” might be reframed as “Be
employed,” or “Be a role model to my children,” or “Live my life with inde-
pendence,” or “ with purpose,” or “with value,” or “with . . . ” whatever
seems to fit for that particular client.
Sometimes such a larger or broad goal can be found during the Evoking
process when clients might be asked about values or what is important in
their lives. Tafrate and colleagues (2018) note that clients who are involved
with the criminal justice system are just as likely to pick positive core val-
ues (and goals) as anyone else. A broad, overarching goal may not make it
to the official probation or child welfare plan of record but can serve as a
backdrop to the rest of the plan. Planning thus ends up being interwoven in
Engaging, Focusing, and Evoking. Once a broad goal is established, areas
of the plan can be generated as subgoals, along with methods of how to
address them. This is where other methods of treatment might be utilized,
such as cognitive-behavioral therapy.
In terms of autonomy support for determining options of a plan, again,
it is helpful to give clients as much choice as is possible, even if the choices
are limited. If a judge orders clients to get anger management therapy or
parenting classes, for example, perhaps clients can at least pick which
agency they would like to attend, based on their needs and its location.
Clients can also be asked to prioritize the subgoals and pick two to three
to begin with (Tafrate et al., 2018). Asking about strengths along with sup-
ports can help in a discussion around barriers (micro, mezzo, or macro) to
achieving each subgoal in order to preplan success (Stinson & Clark, 2017).
Finally, what success will look like in each subgoal may be very different
and can be identified and tied back to the overarching, broader goal.

Vignette and Dialogue Example: Planning

The following is an example of an involuntary client, who is an older adult.

Based on their assessments, social workers and other professionals who
work in APS are to create plans to address clients’ needs for safety. APS is
146 ELEMENTS OF MI

Talking about death and dying is not easy for anyone. The feelings of
awkwardness and fear can be overwhelming to both clients and social
workers. I work with many Chinese older adults, mostly immigrants, who
struggle with different chronic illnesses and mental health issues. When East
meets West, differences in clients’ cultural beliefs and spiritual traditions
sometimes make the end-of-life conversation even more distressing. When
I started my career in an outpatient geriatric clinic, I witnessed a Chinese
patient being emotional and tearful when discussing POLST (provider orders
for life-sustaining treatment) and an advance health care directive with her
medical doctor and social worker. I felt at a loss as to how to support her.
The ultimate goal of having a conversation about the end of life is to
understand our clients’ values and to find out what quality of life means to
them. Everyone wants to die in a good way. They mostly want to be cared
for, supported, and pain-free at the end of their lives. Using MI helps me set
a supportive and nonjudgmental atmosphere that allows clients to talk about
their fears and their ambivalence around planning their death.
The MI personal values card sort (mentioned back in Chapter 5)
is one of the more useful tools that I use with my clients for end-of-life
conversations. This exercise allows my clients to identify those life values
that are most important to them and to weigh these in relation to their
current hesitation on end-of-life care planning. I ask my clients to elaborate
on the values that are very important to them. For example, I might say, “I
see that you value family the most. Why is that?” Then I provide some space
for them to talk about their values and concerns with plenty of reflective
listening. Asking the client, “How is this very important value guiding your
health care decision?” helps me understand my clients’ points of view and to
elicit their feelings about their goals of care.
Death and dying are heavy topics, and it will never get easier to talk
about them. However, using MI skills allows me to guide supportive, yet
open conversations around this difficult topic. It also helps to build an
alliance with my clients, and they experience the medical social worker and
patient relationship as collaborative, which may be different from other
relationships in the traditional medical system.

              Yuen L am Shek, LCSW

              Medical social worker, geriatric focused
              San Francisco, California

usually a county-based agency whose mission is to investigate and inter-

vene with referrals regarding older adults or dependent adults ages 18–64
regarding allegations of physical, financial, or emotional abuse and/or self-
neglect. Self-neglect is the most common referral to APS and is character-
 Planning 147

ized by intentional and nonintentional behaviors such as lack of adequate

diet and/or malnutrition, impaired living conditions such as toilets and
kitchens that do not function, lack of heat, hoarding and garbage accumu-
lation creating fire hazards, poor personal hygiene, and untreated health
conditions (Iris, Conrad, & Ridings, 2014; Mosqueda & Dong, 2011).
Older adults who self-neglect are at a higher risk of morbidity and mortal-
ity as well as other types of elder abuse (Dong, Simon, & Evans, 2013).
The client is Mrs. Tanaka, an 82-year-old Japanese woman who emi-
grated to the United States about 20 years ago. She lives in an apartment
building in a neighborhood that is transitioning from a large Asian popula-
tion to one with residents who are mainly immigrants from Central Amer-
ica. She was referred to APS by her neighbor’s daughter, who was in the
process of moving her own mother out of the building. She ran into Mrs.
Tanaka in the hallway and was shocked by the difference in her appear-
ance; she had lost a great deal of weight and seemed unsteady on her feet.
She could see into her apartment and saw that it contained a lot of bags of
garbage in the doorway. The caller explained that Mrs. Tanaka is a widow
and her son, her only child, passed away last year. She has no other relatives
in the United States that the caller knew of. A second call was initiated by
a home health care nurse due to Mrs. Tanaka turning her away and only
allowing intermittent visits. She had had a hip fracture earlier in the year,
had been to rehabilitation care, and came home with a walker, which the
nurse reported she didn’t use when she was able to see her.
An APS social worker met with Mrs. Tanaka, assessed her situation,
and substantiated self-neglect. Mrs. Tanaka said she had lost weight, wasn’t
sleeping well, she had little food in the apartment, and her stove was not
working. She stated she had lost weight as she didn’t have much appetite.
She sometimes paid a neighbor to shop for groceries for her. There were
bags of trash by the front door but otherwise the apartment was neat. She
said she was unable to carry out her trash because it was a long way to the
bin that was in the alley behind her building and she couldn’t lift the lid. She
had not seen a doctor for herself since her discharge from the rehabilitation
program. She is able to manage her financial affairs but is now unable to
walk to her local bank. Mrs. Tanaka doesn’t like to go out much anyway,
as she isn’t confident in her English and worries that she could get lost and
not be able to read the street signs. She mainly spends her days watching
TV and reading. She appeared cognizant of her situation and surroundings.
Based on the assessment, the APS social worker was concerned about
Mrs. Tanaka’s physical and mental health needs along with her lack of
access to food, isolation, inability to cook due to the stove not functioning,
lack of medical care, and issues with the trash accumulation. The following
is their conversation about next steps, which would be a broad intervention
plan with subgoals and steps. The target behavior was for Mrs. Tanaka to
148 ELEMENTS OF MI

stay independent with a focus on her health and safety. The social worker
worked with a translator (Ms. Sato) who is fluent in Japanese. The dis-
cussion below occurred after the Engaging and Evoking processes. (SW =
social worker; C = client; [MI skills/OARS are in brackets]; change talk is
underlined.)

SW: Mrs. Tanaka, thank you again for meeting with me and Ms. Sato
today and discussing your situation with us. I was wondering if
it would be ok with you to discuss a little bit more about the ser-
vices we offer that might be of benefit to you. [autonomy support;
closed question]
C: Well, as we talked about already, I live here by myself. I’ve been in
this apartment for 20 years and I have no plans to leave. I take
care of myself and pay my bills. I think I am doing all right. I was
sorry to see my neighbor move; she had been my friend here the
whole time. The older you get, the less people you have in your
life. But I have a few other neighbors that I can rely on, it’s just
hard as we have to communicate in English and I don’t know
them as well as my friend who just moved.
SW: You’ve had a lot of losses in the last few years, with your hus-
band’s illness and death, your son’s unexpected death, your friend
moving, and other people you know leaving your neighborhood.
You have been able to reach out to a have another neighbor help
you. Being independent is very important to you and one of my
goals is that you stay safe and healthy in order to stay indepen-
dent. You have taken care of yourself, including paying your
bills. Sometimes though it gets harder when it’s just you alone.
What thoughts do you have on how you can stay independent
and healthy? [summary; complex reflection; sharing information;
open question]
C: I don’t mind being alone, well, most of the time. You’re right about
that. I want to stay independent. Maybe I could use a little help
with small tasks, like the garbage and getting the stove fixed. Is
that something you could help me with?
SW: Yes, it is. Would you like to hear about how that might work?
(Client nods yes.) We have a program through the county that
provides personal care and homemaking assistance. You could
have someone come here maybe two mornings a week, to do these
chores. She could also take you to a store where you could buy
groceries that are more in line with what you like to eat. She could
help you do laundry. What do you think about that? [autonomy
support; closed question; sharing information; open question]
 Planning 149

C: That would be helpful, as long as we could communicate with each

other. And I would want someone who I could trust.
SW: It’s important to you to have someone who you trust. You would
choose and hire the person you’re most comfortable with. What
other things could we help you with? [simple reflection; sharing
information; open question]
C: Could this person take me to the doctor? Like we talked about,
I haven’t been in a long time and I think I would like to do this.
SW: Yes, she can do that, too, and that’s something I can help you with
if you want, that is, to set up an appointment. [sharing informa-
tion]
C: I can go to my husband’s doctor. He speaks Japanese and is a nice
man.
SW: You have had a good relationship with him in the past. [complex
reflection]
C: Yes, he was very good to my husband.
SW: He was kind to him and would be kind to you. Getting a medical
checkup is a great idea. Would you be interested in hearing about
some other ideas of how we might help? [complex reflection; affir-
mation; autonomy support; closed question]
C: Yes, but having someone come here twice a week will probably be
enough.
SW: It gets hard and sometimes it’s bothersome to cook for yourself
when you live alone. [complex reflection]
C: I don’t need much to eat. But I don’t like the food that store has.
SW: Can I ask you a question? (Client nods yes.) Maybe you would
be interested in home-delivered meals? They deliver a hot meal
to people at lunchtime every day. We work with a senior pro-
gram that is for Asian older adults and their home-delivered meals
program cooks foods that you are probably more familiar with.
[autonomy support; closed question; sharing information]
C: How much does that cost?
SW: There is no cost to you. [sharing information]
C: An Asian senior program? What’s that? Where is it?
SW: It’s called Senior Services and it is located about 2 miles from here.
Sounds like you are unfamiliar with them. Would you like to hear
more about their services? [sharing information; simple reflection;
autonomy support; closed question]
C: Yes, I’ve never heard of them.
150 ELEMENTS OF MI

SW: Not only do they have the home-delivered meals, they have hot
lunches on site Monday through Friday. They also have classes as
well as social activities. They provide transportation that actually
comes into your neighborhood. [sharing information]
C: Could the person who is my helper take me there? (Social worker
nods yes.) I think I would like to check it out, but it would be
easier if she took me the first time. Maybe if I like it, you or she
could help me figure out how to get a ride with them. I could walk
in the door if I used my walker.
SW: We can certainly do that. It isn’t always easy going somewhere
new and you are thinking of some ways to do this. What do you
think about the home-delivered meals program? [sharing infor-
mation; affirmation; open question]
C: That is something that I think would be helpful. Can you sign me
up?
SW: Yes I can. I’m glad you are taking these steps to take care of your-
self. I have one other question. Tell me about the home health
nurse and your experience with her. [affirmation; open question]
C: She was nice enough, but I didn’t want her to come here. I just
wanted to be left alone. But, talking to you has given me some
hope that maybe things can get a little better, and I am realizing
that I do need some help to stay independent. Can you ask her to
come back?
SW: Yes, that is something I can do. Let’s summarize everything and
see where we are. You want me to get the ball rolling on applying
for in-home care so that you can get a support worker to come
here twice a week, to help you with some daily chores and maybe
take you to appointments and to the Senior Services program.
You want me to sign you up for the home-delivered meals and ask
the home health nurse to start coming to see you again. You are
willing to go see your doctor to get a checkup. What other things
would you like to talk about or think about doing to help you stay
independent, safe, and healthy? [sharing information; summary;
open question]
C: I want to stay independent and of course healthy and safe, but this
all seems like a lot. I still need my time alone to read and watch
TV. But I am glad to get the help and the meals.
SW: It’s a lot and hopefully these different steps will make things easier
for you, so you can still get your reading time and be comfort-
able. Can I ask you a question? Would you be willing to call your
doctor while I am still here to make an appointment? I can have a
 Planning 151

support worker here for you to interview by early next week and if
you like her, she can start right away, so you could see the doctor
by the middle of next week. The home-delivered meals will come
starting tomorrow. [complex reflection; autonomy support; closed
question; sharing information]
C: Yes, I can do this. (Makes the call to her doctor.) They gave me an
appointment for later next week. I told them that I hadn’t been in
to see him in a long time and that I need a checkup.
SW: That’s great, thanks for doing that. You’re taking some good steps
here to take care of yourself. How about if we meet next week
after your doctor’s appointment and you can tell me how the visit
went, how you like the home-delivered meals, and about the sup-
port worker? You have my phone number if you have any ques-
tions or want to reach me for some reason before we meet. When
might be a good time to meet again? [affirmation; closed question;
sharing information]

They finished the meeting by setting an appointment for the follow-

ing week. Based on her assessment, the social worker knew that the plan
for Mrs. Tanaka would need to entail (1) getting Mrs. Tanaka evaluated
medically and having it done fairly quickly; (2) arranging for support ser-
vices to help her with daily household tasks, including cleaning out the
garbage, getting the stove fixed, and medical appointment transportation;
(3) increasing her access to nutritious food by arranging for consistent food
delivery; (4) increasing her social support; and (5) arranging for the home
health nurse to return.
The APS social worker would also like to ask Mrs. Tanaka, in their
next visit, to identify any support person in her life who might be able to
help her in any way and/or be considered for financial power of attorney,
should that be needed. Mrs. Tanaka is in a position to be financially abused
if she starts to have problems with managing her finances. This could be a
difficult conversation, as no one likes to think of themselves as not being
competent. The home health social worker could assist her with this and
other aspects of end-of-life planning, which includes a power-of-attorney
appointment as well as advance directives. The use of MI and SDM in
end-of-life planning, specifically advance directives, has been found to be
useful in terms of engaging clients in difficult decisions (Austin, Mohottige,
Sudore, Smith, & Hanson, 2015; Fried, Leung, Blakley, & Martino, 2018;
Ko et al., 2016; Nedjat-Haiem et al., 2018).
The social worker didn’t tell Mrs. Tanaka what the overall specific
APS plan would need to address but invited her to think about ways to stay
independent (her own goal) and healthy/safe (the social worker’s overall
152 ELEMENTS OF MI

goal). Mrs. Tanaka was able to come up with ideas that were fairly consis-
tent with the APS social worker’s goal of enhancing Mrs. Tanaka’s safety in
her home. The social worker also provided information about services that
were available and elicited her thoughts about those, and affirmed her deci-
sions. Had she not voluntarily brought up going to the doctor, for instance,
the social worker would have asked for permission to provide advice about
getting a medical assessment and the need to have it done quickly. Dur-
ing their discussion, some ambivalence reemerged after hearing the social
worker’s summary, which the social worker reflected and reframed as these
tasks are to make things easier for Mrs. Tanaka.
The process of Planning was collaborative. The social worker sup-
ported Mrs. Tanaka’s goal of staying in her apartment as well as being as
independent as possible. She also asked Mrs. Tanaka to complete a task,
which was to make an appointment with the doctor of her choosing. The
primary care physician will assess Mrs. Tanaka for depression and any
health issues. Having a translator available as well as a referral to culturally
based services increases the likelihood of client engagement and follow-
through (Tsai & Lopez, 1998).
On a side note, there are few studies that have examined the use of
MI with translator/interpreter services. Nursing researchers in Australia
conducted MI phone interviews regarding medication adherence with older
adult participants, in Italian, Greek, or Vietnamese. The researchers noted
that having a third person in the conversation made the conversations less
spontaneous and required careful, advance planning to maintain fidelity
to the MI intervention (Williams, Manias, Cross, & Crawford, 2014). In
another study, support staff who worked with refugees identified barri-
ers and facilitators in using MI with their clients. Some of the staff felt
that interpreters did not always utilize open questions that tended to be
abstract but used closed questions that were more concrete, evidenced by
the answers clients gave (Potocky & Guskovict, 2019). While not always
feasible, perhaps interpreters should be trained in MI if it is to be consis-
tently used in their work. Obviously this is an area ripe for further research.

Final Thoughts

As the last of the four processes, Planning requires that you continue in
the spirit of MI and utilize OARS skills to keep it a collaborative discus-
sion. Because change isn’t easy, you may move through the first three of
the four processes (why) and never get to Planning (how) due to clients’
ambivalence or lack of confidence. This may require you to circle back
through Engaging, Focusing, and Evoking as needed. Working in systems
where there are preestablished plans or expectations is extra challenging
 Planning 153

and may mean a lot of time spent in Engaging and Evoking in order to get
to know your clients, their values, and their goals, and to think about how
to create a motivating overarching goal to tie the various components of
the plan together. After plans are discussed and clients are committed to
taking the specified steps, you can be supportive, and re-plan as needed,
especially as subgoals/objectives are achieved.

EPAS Discussion Questions

EPAS 7: Assess Individuals, Families, Groups, Organizations, and Communities

 Develop mutually agreed upon intervention goals and objectives based on
the critical assessment of strengths, needs, and challenges with clients and
constituencies.

EPAS 8: Intervene with Individuals, Families, Groups, Organizations, and

Communities
 Critically choose and implement interventions to achieve practice goals
and enhance capacities of clients and constituencies.

1. How do you know now when your clients are ready to move from
why to how? What signals do you look for?
2. How are intervention goals and objectives mutually developed
in your work setting or internship site? If they aren’t done in a
collaborative manner, how might you move in that direction?
3. Are there types of clients or situations where you or your
colleagues are less collaborative in goal setting and intervention
planning? What are your thoughts on how you or your agency
work with riskier clients?
 PA RT III
Implementation
 C hapte r 9

Integrating Motivational Interviewing

into Social Work Practice
with Cristine Urquhart and Fredrik Eliasson

EPAS 4: Engage in Practice-Informed Research and Research-Informed

Practice
 Use and translate research evidence to inform practice, policy, and
service delivery. (CSWE, 2015, p. 8)

“Can you come do a half-day training in MI for our staff?”; “We want
someone to train about MI over our monthly Lunch and Learn—is that
something that you can do?”; “We’re looking to train all of our social
workers in MI. What is the best way to do it?” These are the types of
requests and questions that MI trainers often get. By now most human
service practitioners have heard of MI. There is an interest in it and in the
training of it, which is a good thing. Those who have read through the rest
of this book would probably agree with the statement that MI is simple
but not easy (Miller & Rollnick, 2013). Like many other evidence-based
practices (EBPs; intervention models based on rigorous research studies),
translating how MI can work in the everyday social work settings and
learning and applying new skills with consistency are not things that can
be done over the lunch hour or even in a day or two of a workshop. What
is known about integrating MI in social work practice? Implementation
science, which is research on the best ways to transfer science or EBPs into
157
158 IMPLEMENTATION

real-life medical and social service practice, provides some knowledge and
guidelines (Bauer, Damschroder, Hagedorn, Smith, & Kilbourne, 2015;
Fixsen, Blase, Naoom, & Wallace, 2009). MI training studies present some
specific answers:

• Knowledge from reading a book or a short presentation does not

transfer into skill change.
• Participating in a 2-day training of MI that includes practice of skills
with feedback can produce skill change in the short run.
• MI skill change over time is usually not maintained; some feedback
and coaching based on observed practice are needed to enhance and
maintain skill gain from an initial training.
• Proficiency in MI is associated with better outcomes with our clients
(Bogue & Nandi, 2012; Carpenter et al., 2012; Miller & Moyers,
2017; Schwalbe et al., 2014; Wain et al., 2015)

Because of the pressing needs of clients and the limited resources

to address them, it is important to know what interventions work and
ways to increase the uptake of science into practice (Bauer et al., 2015).
The following addresses the above-listed points regarding MI integration/
implementation. Also, I have invited social work practitioners who have
worked to train and implement MI into micro, mezzo, and macro settings
to describe their experiences.

Knowledge Does Not Transfer into Skill Change

Implementation science states that the best way to develop skills is through
training combined with feedback and ongoing coaching (Fixsen, Blase, &
Van Dyke, 2019). Change is difficult and it is human nature to resist change,
even if it is something that we think we want (Bertram, Blase, & Fixsen,
2015). I might hear a flute being played, think it is beautiful, and want to
do it. I may even have a background in music, but that doesn’t mean I can
just pick up a flute and play it, much less the lovely melody that had sparked
my interest. I might decide that it is just too hard and go back to playing
the instrument that I am familiar with. Reading about or even observing
a certain practice skill or model of intervention may stimulate interest but
not change behavior, especially if it is difficult or feels uncomfortable.
Why is learning MI uncomfortable? Partly it is because you might
feel vulnerable when trying something new, even if it seems a bit famil-
iar. Before I review what is needed to increase skills in MI, I want to step
back and look at what current practice behaviors get in the way of learning
MI and may need to be unlearned (Miller & Rollnick, 2013). In our own
 Integrating MI into Social Work Practice 159

research with social work undergraduate students in their MI classes, at a

pretest of responding to hypothetical client statements, 18% confronted or
warned clients, another 18% gave advice or suggestions on how to solve
their concerns, 19% asked questions (instead of providing reflective listen-
ing statements), and another 6% praised or gave reassurance, all of which
are inconsistent with MI (Hohman et al., 2015). Throughout the semester
students had to work on overcoming their tendency to want to tell clients
what to do or to engage in the question–answer trap. Fortunately, their
scores improved significantly by the end of the semester to be more consis-
tent with MI and the above-listed behaviors rarely occurred.
Schumacher, Madson, and Nilsen (2014) surveyed 146 MI trainers
asking basically the same question: What are the inconsistent MI behaviors
or habits that conflict with learning MI as seen in their trainees who were
community-based professionals? Trainee groups were categorized as medi-
cal, mental health, substance use, or criminal justice. For learning pur-
poses, I want to look at the mental health professionals who were trainees.
The main behaviors observed in training role or real plays by their trainers
were as follows (more than one behavior could be listed): confronting or
arguing with clients (72%), asking a lot of questions (64%), focusing too
early on solving the problem (63%), arguing for change (58%), and assum-
ing the expert role (63%). Other barriers to learning MI were that trainees
had difficulty with reprogramming from other models (67%), believed they
were already doing MI (63%), and had low self-efficacy that they could
learn MI (56%). MI trainers address these issues through content presenta-
tion but even more so through modeling MI behaviors while teaching as
well as in giving feedback during skill practice (MINT, 2019; Schumacher
et al., 2014).

Training Does Impact MI Skill Development . . . Initially

MI training should include a combination of content, demonstration, and

practice (Miller & Rollnick, 2013; MINT, 2019). Studies based on MI
trainings with these elements have found immediate skill change, which
sometimes is measured by role plays with simulated clients (actors) as post-
tests to training (Barwick et al., 2012). Who is likely to respond well to MI
training? Mostly there are no demographic, ethnic, educational, or person-
ality characteristics that impact learning MI by community-based practi-
tioners (Baer et al., 2009; Hartzler, Baer, Dunn, Rosengren, & Wells, 2007;
Miller et al., 2004, 2008; Miller & Rollnick, 2013; Mitcheson, Bhavsar, &
McCambridge, 2009). A study of substance use disorder clinician trainees
found that those who were more empathetic or client-centered at pretest
tended to score higher in MI skills at posttest, which was also found in
160 IMPLEMENTATION

another study of psychology students (Carpenter et al., 2012; Schumacher

et al., 2018). Clinicians with more experience have been found to have a
harder time learning MI (i.e., overcoming other models/skills); other stud-
ies found that experience (or lack of it) made no difference in demonstrat-
ing MI skills after training, while a meta-analysis found that clinicians
with more experience fared best (Carpenter et al., 2012; de Roten, Zim-
mermann, Ortega, & Despland, 2013). A study of mandated trainees from
juvenile corrections found that level of motivation to use MI at the begin-
ning of training made no difference in skill attainment; however, females
with higher education levels tended to rate highest at posttest (Hohman,
Doran, & Koutsenok, 2009).
What should be covered in an MI training? Curriculum-wise, Miller
and Rollnick (2013) suggest that four topics be covered. The topics include
(1) MI knowledge and spirit, (2) engaging, (3) focusing and evoking, and
(4) planning. A pretraining assessment can indicate what to specifically
address, for instance, if client-centered skills in the trainees are already
strong, then the bulk of the training could focus on recognizing and evok-
ing change talk. Training should include a mixture of content as covered in
this book, skill demonstration, and experiential exercises for skill rehearsal
(MINT, 2019).
As with training for any EBP, prior to the actual training event, trainers
should understand the training needs, culture, and context of the agency/
program setting, along with client characteristics, and adjust the training
content accordingly (Bertram et al., 2015). For example, in our work with
training juvenile corrections staff, we worked closely with administrators
and managers in designing how training would be implemented along
with follow-up assessment and training for internal trainers. We antici-
pated ambivalence as training attendance was mandatory. We also utilized
criminal justice–involved adolescent examples in the training content and
skill practice exercises (Hohman et al., 2009). Having overall administra-
tive support as well as internal support staff to help address specific train-
ing needs, known as leadership drivers and organizational drivers in EBP
implementation, increases the effectiveness of training (Fixsen et al., 2019).
Organizational culture, as indicated above, can provide supports or
barriers to adopting the spirit and use of MI. If practitioners perceive that
decisions are being made without their input and they have little knowl-
edge about what MI entails prior to training, trainees may be more likely
to believe that using MI will add to their workload and will not be as
invested in using it. Mandating employees to MI training is difficult, as it
goes against the spirit of MI. One method for an agency that is looking to
implement a more client-centered culture via MI would be to only initially
send those to training and coaching who already have this orientation,
want to learn MI, and can become champions of MI to their peers (Bertram
 Integrating MI into Social Work Practice 161

et al., 2015; Bogue & Nandi, 2012). Organizations that have a culture of
being open to change and encouraging staff to try new practices are more
likely to see gains in MI skill (Baer et al., 2009; Berger, Otto-Salaj, Stoffel,
Hernandez-Meier, & Gromoske, 2009). Programs or organizations that
are less aligned with the spirit of MI, that is, those for whom the use of
MI would be a major cultural shift away from authoritative methods with
clients, may need more intensive work throughout the pretraining, training,
and follow-up processes (Barth et al., 2017; Bogue & Nandi, 2012; Fixsen
et al., 2019; Sage, 2019). Usually, MI trainers will then focus on pretrain-
ing needs and overall goals, to help address organizational paradigm shifts
that are needed to support any EBP that is being implemented (Bertram et
al., 2015). Miller and Moyers (2016) also suggest that in creating organi-
zational change to more client-centered work, programs examine hiring
practices where potential new employees could be prescreened for empathy
and at least a beginning level of MI skill proficiency.
Who should be hired as a trainer? Of course, proficiency with skills and
knowledge of MI are imperative, along with an ability to demonstrate an
MI interview, model MI in the training, and manage a classroom (MINT,
2019). MINT has a rigorous application process to ensure that candidates
who participate in the training of new trainers meet these requirements.
MI trainer certification has recently been introduced in MINT. However,
there is no practitioner certification at this time. If you are seeking an MI
trainer, MINT trainers located in various geographic areas, both nation-
ally and internationally, can be found through visiting www.motivation-
alinterviewing.org.
A final question regarding training of MI: Does the mode of training
make a difference? Most trainings are conducted classroom-style but other
avenues are being investigated, such as the use of virtual classrooms or
online courses. With the onset of the COVID-19 pandemic, many trainings
had to be converted to a virtual format. Mitchell and colleagues (2011)
tested the feasibility, acceptability, and effectiveness of an interactive vir-
tual platform for training MI with physicians. Using a fidelity measure,
they found that the physicians gained in MI skills and found the platform
to be acceptable. Another study of online training of physicians as well as
social workers and psychologists found similar MI skill gain, when com-
pared with in-person training format (Mullin, Saver, Savageau, Forsberg,
& Forsberg, 2016).
Within trainings, studies have examined the use of standardized
patients (actors) as compared to using peers in real plays (using one’s own
content in a simulated setting) and have found no differences in MI skill
gain (Lane, Hood, & Rollnick, 2008). Pecukonis and colleagues (2016)
utilized live supervision during MI training (observation and immediate
feedback from supervisors during practice with standardized clients) with
162 IMPLEMENTATION

child welfare social work students. The comparison group was trained in
MI by self-administered online modules. Results found that those receiv-
ing the live supervision and peer feedback improved significantly in their
MI skills and these skills were maintained over time, as compared to the
teaching-as-usual group (self-administered online modules) (Barth et al.,
2017). Live supervision is labor-intensive in that it requires training field
supervisors or instructors, as well as devoting time to the actual supervi-
sion (Barth et al., 2017). Interactive online models that provide immediate
feedback and coaching may be one way to address this (Apodaca, 2016;
Vasoya et al., 2019).

Independent Observation, Feedback, and Coaching

Are Needed to Maintain Skill Gain
Independent Observation: MI Fidelity Measures
As has been found in studies of other types of EBPs, skills learned in train-
ing, even training where there is plenty of opportunity for practice via role
play, are not maintained over time and need to be continually practiced
and reinforced (Fixsen et al., 2009). This is true for MI as well (Barwick et
al., 2012; Hall, Staiger, Simpson, Best, & Lubman, 2015; Schwalbe et al.,
2014). Fidelity measures are used to determine proficiency in EBPs. They
set the bar to indicate that yes, this person can demonstrate the particular
required skill/model. Fidelity to any model is important in order to truly
impact client outcomes.
What are the fidelity measures of MI? A recent systematic review iden-
tified 12 different tools that were studied in 103 articles (Gill, Oster, &
Lawn, 2019). A scoping review, which tends to look at all the research in an
area of interest, found 28 fidelity measures (Lundahl et al., 2019). Some of
the measures in this analysis included client-report measures, one of which
is mentioned below, as well as self-assessment measures. Most required
trained raters and the use of audiotapes that are coded using the standards
of the measure.
One of the most frequently used tools at the time of this writing, devel-
oped for both research monitoring as well as clinical work, is the Moti-
vational Interviewing Treatment Integrity measure, version 4.2 (MITI4.2;
Moyers, Manuel, & Ernst, 2014; Moyers, Rowell, Manuel, Ernst, &
Houck, 2016). It was modified from previous versions to be more in line
with the four processes. The measure includes behavior counts (questions,
complex reflections, autonomy-support statements/questions, persuading
with permission, among others) as well as what are called global ratings
regarding change talk, sustain talk, empathy, and partnership. Scoring of
global ratings is based on a 5-point scale with anchor points that have
 Integrating MI into Social Work Practice 163

qualitative descriptions. The MITI4.2 has been found to have good reliabil-
ity and concurrent validity with other measures. Only practitioner speech is
coded in this instrument, as compared to others that include coding client
speech. Thresholds for fair proficiency are 40% complex reflections (of all
reflections) and 50% for good proficiency. The ratio of all reflections to
questions for fair is 1:1 and for good is 2:1. The thresholds for the global
scores are still being studied (Moyers et al., 2014).
A fidelity instrument that has been developed specifically for support
to practitioners in achieving proficiency in MI skills is the Motivational
Interviewing Competency Assessment (MICA; Jackson, Butterworth, Hall,
& Gilbert, 2015). This coding tool requires an audio file of a practitioner–
client session of at least 8 minutes in length. The session is assessed based
on (1) intentions: expressing empathy, partnering, evoking, guiding, and
supporting autonomy and activation; (2) strategies: responding strategi-
cally to sustain talk and responding strategically to change talk; and (3)
microskills: reflections and questions that form a reflection to question
ratio. Scores are assigned from a scale of 1 (fundamentally inconsistent
with MI), 2 (generally inconsistent with MI), 3 (client-centered), 4 (com-
petent in MI), and 5 (proficient in MI). Narratives and examples for each
strategy and intention scoring are provided (Jackson et al., 2015). The
MICA has been found to have good internal reliability, interrater reliabil-
ity, and convergent validity with the MITI (Vossen, Burduli, & Barbosa-
Leiker, 2018).
The MICA has also been adapted for live observation of practitioner–
client interactions. The A-MICA is a condensed version of the MICA. The
A-MICA merges strategies and intentions into five scales with three ratings
available for each. The scales are:

1. Partnering for change

2. Expressing empathy for change
3. Guiding toward change
4. Evoking for change
5. Supporting autonomy and activation for change

Descriptive items and examples are provided for each. The A-MICA is
currently in use within organizations for live and recorded work sample
observation and feedback, and is being evaluated for reliability and valid-
ity that includes comparisons with other fidelity instrument ratings of the
same interviews (A. Hall, personal communication, October 15, 2019).
Another live observation measure that has been developed is the MI Coach
Rating Scale. It has 12 items and has been tested in HIV clinics that were
implementing MI agencywide (MacDonell et al., 2019; Naar & Flynn,
2015).
164 IMPLEMENTATION

Cresswell Báez, Galanis, and Magill (2020) recently developed and

tested a measure of MI practice that is relatively easy to use by supervi-
sors in community-based settings, making it more likely to be sustainable:
the Motivational Interviewing Evaluation Rubric, or MIER. This measure
has 15 items based on MI spirit, process, and skills that are rated as high,
medium, and low, with qualitative descriptions of each anchor point. Initial
testing found it to have good internal consistency and moderate concurrent
validity with the MITI. The authors note that the MIER can be used within
existing supervision practices.
What about self-evaluation? Is it possible for self-learners of MI or
those who have participated in a workshop to evaluate their own practice
over time? Can you use a fidelity measure to assess yourself? The answer
is: maybe. You would need to be trained in the fidelity measure/coding
first. It may be possible to work with an independent observer to code
several audiotapes and then compare results to determine your skill level
at reliable coding. Studies of self-assessment of MI skills tend not to use
coding tools but ask subjects to use more general ratings, estimates of
OARS skills, and confidence to practice. When these self-assessments are
compared to independently coded audiotapes of interviews, they tend to
be overestimated (Wain et al., 2015). A comparison of therapists, supervi-
sors, and objective observers found that while there was some correspon-
dence of tape ratings between the three groups regarding OARS skills,
there was less agreement between the supervisors and the observers on
the more advanced MI skills, such as eliciting and responding to change
talk. Supervisors tended to be more in line with the therapists’ ratings,
which may be due to positive bias (Martino, Ball, Nich, Frankforter, &
Carroll, 2009).
Computer-based applications that offer voice recognition, automated
coding, and feedback are being developed to help in learning MI. One sys-
tem that has been pilot-tested uses digital recording of a client interview,
an algorithm that codes for MI, and the program then produces a coded
transcript, along with a feedback report. The generated report, which is
obtained on a web portal, contains global and behavior counts along with
session talk time of the therapist and the client. In a pilot-test, therapists
responded positively to the program and indicated that the feedback report
was similar to their own perceptions of the taped interaction. A study of
the program compared the reports with tapes coded by a human coder
using the MITI and found agreement about two-thirds of the time, which
the authors are working on improving (Imel et al., 2019). A program for
medical student training that is being tested with continued development
is the Real-time Assessment of Dialogue in MI (ReadMI). This program
analyzes conversation in real time through a microphone on a laptop and
provides immediate feedback throughout the session, in the presence of a
 Integrating MI into Social Work Practice 165

trainer who facilitates a discussion (Vasoya et al., 2019). Software such as

these programs hold promise as methods for developing MI skills that are
less expensive and less labor-intensive than the use of a trained coder who
provides feedback and coaching. Research will need to determine, however,
if skill growth and maintenance is similar to receiving in-person feedback
and coaching.
While trainees may not be good at estimating their own MI skill level,
clients can provide feedback regarding their interactions with counselors.
Client feedback while in therapy in general is considered important and
has been found to help in professional development (Madson et al., 2015).
Clients may not be able to tabulate specific behavior counts but they can
recognize aspects of MI spirit (Madson, Bullock, Speed, & Hodges, 2009;
Madson et al., 2013; Marcus, Westra, Angus, & Kertes, 2011). The Cli-
ent Evaluation of Motivational Interviewing scale (CEMI) was developed
to augment objective coder feedback by providing information about the
client’s experiences in MI interviews. The CEMI is a 12-item scale that is
rated from 1 (not at all) to 4 (a great deal). It is given to clients at the end
of a counseling session. Sample items include “How much did your coun-
selor . . . emphasize your strengths? . . . Act as a partner in your behavior
change? . . . Act as an authority on your life?” Some of the items, such as
the last one, are reverse-scored. Scores are summed, with higher scores
indicating more adherence to MI. Studies have found that the items are
related to the relational and technical aspects of MI with mixed reliabil-
ity results but also good validity (Madson et al., 2013, 2015; Madson,
Villarosa, Schumacher, & Mohn, 2016). The CEMI in these studies was
tested on a variety of client samples. A recent study of its use with proba-
tion clients found the same two factors of relational and technical items.
The authors of this study proposed that the CEMI may be a cost-effective
way to monitor use of MI-consistent communication (Armstrong, Atkin-
Plunk, & Gartner, 2016).
We developed and tested a similar scale that was designed to be used
within residential substance use settings where clients interact with many
different staff. The goal was to determine how well the climate of the
program/organization overall was aligned with the MI spirit as rated by
clients. The Motivational Interviewing Measure of Staff Interaction, or
MIMSI, is a 10-item measure rated on a 5-point scale of 1 (never) to 5
(always). Sample items include “The staff here seem to think I know what
is best for myself”; “The staff here is curious about my thoughts and feel-
ings”; and “I feel hurried and rushed when talking with staff.” Three fac-
tors (collaboration, evocation, and autonomy support) were determined
along with concurrent validity with a measure of therapeutic alliance
(Hohman & Matulich, 2010). Further testing is needed on both of these
scales as to how well clients experience MI (Boyle et al., 2019).
166 IMPLEMENTATION

Coaching
Coaching, while used in other professions such as education, business, and
medicine, is still somewhat new in human services (Akin, 2016). Its use has
spread to child welfare practice; for the past 10 years, the Northern Cali-
fornia Training Academy, with a focus on implementation of a statewide
practice model, has utilized coaches in 11 county child welfare departments
(Hafer & Brooks, 2013). Implementation science tells us that on-the-job
coaching is needed to integrate and apply skills/frameworks learned in
training with fidelity (Fixsen et al., 2019). Coaching provides support and
feedback and should be individualized to the trainee due to differences in
learning (Akin, 2016; Bertram et al., 2015).
What are the elements of a good coach? Coaches should have a back-
ground and knowledge of the EBP being implemented, fidelity measures,
and experience in the context where the coaching occurs. They can be from
outside of the organization or from inside it, such as clinical supervisors
or peers (Bogue & Nandi, 2012). External coaches may be off-site and
use telephone-based methods (Barac, Kimber, Johnson, & Barwick, 2018;
Smith et al., 2012). Coaches should develop individual learning plans in
collaboration with the trainee and have a consistent schedule of when to
meet. They either directly observe or listen to audiotapes of client sessions
and should show accountability that trainees are learning over time (Fixsen
et al., 2019). Learning plans should shift as skills are incorporated, again
fitting the need of the trainee/social worker as well as the setting of the
work. In a study from the Northern California Training Academy, child
welfare social workers who received coaching on a practice model (not MI)
indicated that coaching had a positive impact on their work (71%), along
with increased motivation (63%), new knowledge (50%), and an improved
sense of empowerment (41%) (Hafer & Allen, 2019). Another study found
that trainees appreciated coaches who were knowledgeable and provided
strengths-based feedback and collaboration around skill building (Akin,
2016).
Indeed, MI coaches should model the MI spirit and behaviors in all
of their coaching interactions (Gunderson et al., 2018). MINT encour-
ages coaches to first emphasize the trainee strengths and focus only on
one or two areas to improve practice, which is selected by the trainee in
consultation with the coach (MINT, 2019). It has been suggested that MI
could be useful as an individual coaching strategy in general as well as
an implementation strategy of other EBPs (Hettema, Ernst, Williams, &
Miller, 2014).
Provision of feedback of audiotape coding or observation results with
coaching over several months or a year tends to have the best outcomes in
 Integrating MI into Social Work Practice 167

terms of skill proficiency and maintenance (Miller et al., 2004). Studies

have found that the number of feedback/coaching sessions needed to obtain
and sustain MI proficiency (as measured by the MITI) range from 4 to 20,
which seems to be dependent on initial trainee empathy, openness to client
autonomy, and reflective listening skills as measured at baseline (Schum-
acher et al., 2018; Schwalbe et al., 2014). A study of 90 probation officers
found that after receiving MI training, feedback, and coaching, about 50%
were proficient in MI by their eighth tape (Bogue, Pampel, & Pasini-Hall,
2013).
Posttraining coaching for trainees requires the employer to provide
the encouragement, structure, and time to participate (Fixsen et al., 2019).
Schwalbe and colleagues (2014) found problems with attrition of trainees
regarding participation in the coaching. Making audiotapes available for
coding, feedback, and coaching is often a difficult process in that train-
ees have problems with time constraints, work demands, and possibly per-
formance anxiety; thus, some don’t follow through with submitting tapes
(Crouch & Parrish, 2015; Doumas, Miller, & Esp, 2019). Some trainees
think that it can also be difficult to get clients to consent to being taped,
though that usually is not an issue (Baer et al., 2004; Bennett et al., 2007;
Forrester, McCambridge, Waissbein, & Rollnick, 2008; Moyers, Manuel,
et al., 2007).
Live observation with feedback and coaching may address some of
the logistical issues that cause attrition from participation in submitting
tapes and coaching. One study, however, found that those who received live
observation and coaching did not improve as much as those who submitted
tapes for coding and coaching (Bogue et al., 2013). This may be due to the
need to determine if live observation coding is equivalent to taped cod-
ing, which tends to be more detailed. On the other hand, live observation
may be beneficial to practitioners by providing immediate opportunities to
apply MI in real time in a session, particularly in difficult client situations,
whereby the coach can participate and model skills.
Snyder, Lawrence, Weatherholt, and Nagy (2012) reported on a county
child welfare agency that hired a full-time clinical coach who was a mem-
ber of MINT. She accompanied social workers on at least two home visits
per month, where she was able to observe the social workers as well as
model MI such as described above, during the client meeting, when needed.
She used a modified version of the MITI and would then discuss the home
visit, her observations, and coding scores afterward in the car with the
social workers. A different MI trainer conducted initial trainings and then
monthly meetings for additional training and practice, which the clinical
coach also attended. The social workers reported how they saw their rela-
tionships with families change as they used more MI skills. They identified
168 IMPLEMENTATION

that the coaching was helpful through modeling, as were the postvisit dis-
cussions. The social workers advocated to move from the large group train-
ing and discussion format to the use of taped (and MITI coded) interviews
for review in small group supervision (Snyder et al., 2012).
Some people thrive in small groups and greater MI skill gain has been
found in small group training with supervision as compared to larger train-
ing groups (Schwalbe et al., 2014). Employers can provide opportunities
for skill development that aren’t as labor-intensive as working with an
individual coach, by creating communities of practice or peer or clinical
supervision groups. Such groups can also be created outside of one’s work
setting. Communities of practice is defined as “groups of people who share
a concern or a passion for something they do and learn how to do it better
as they interact regularly” (Wenger, 2009, p. 1). They have been used by a
variety of helping professionals for skill development (Barwick, Peters, &
Boydell, 2009; Bogue et al., 2013; Wilding, Curtin, & Whiteford, 2012).
For MI skill development, the group needs to be structured, safe, and con-
sistent. Members should all have the same baseline training in MI and some
knowledge of coding, even if it is simply doing behavior counts of OARS
skills. These groups can involve shared reading, videos on MI, feedback
on members’ audiotapes, or feedback on a live real-play demonstration
(MINT, 2019). Having someone proficient in MI and coding or occasional
check-in is needed to keep group members on track regarding skills (MINT,
2019). Currently, there is no research on gains in MI skill proficiency due
to the use of consistently attended communities of practice as compared to
individualized coaching.
Based on the many research findings of training and implementing MI,
Table 9.1 provides a guideline for creating MI learning plans at the indi-
vidual (micro) level, the unit (mezzo) level, and agencywide (macro) levels.

Individual Learning Plans

In creating your own individualized learning plan, it is important to go
beyond reading books on MI. Attending several community-based trainings
or a semester-long university course is helpful in making skill gain; working
with an expert MI trainer who provides audiotape coding, feedback, and
coaching will help consolidate training gains as well as give opportunities
for continued practice under supervision. Anecdotally, trainees report that
attending a MITI coding class also increases their own awareness to pay
attention to the minute details in their communication with clients. Feed-
back from clients can also provide important information. Once you have
received proficiency in MI, as designated by the MITI, you still might want
to attend a refresher training or submit a tape to a coach every once in a
while to address possible skill drift.
 Integrating MI into Social Work Practice 169

TABLE 9.1. Integration of MI into Social Work Practice: Micro, Mezzo,

and Macro
Individual practice Unit in agency Agencywide
Basic MI 2- to 4-hour Read MI books/articles Administration vision and support
overview Introductory workshop Input from supervisors, staff, and
Read MI books/articles (1–2 days) and clients
Introductory workshop advanced workshop Logistics planning with MI trainers
(1–2 days) and (2–3 days)
Curriculum development
advanced workshop Audiotape coding,
(2–3 days) feedback, and coaching Introductory workshop (1–2 days)
and advanced workshop (2–3 days)
or Live observation with
feedback Audiotape coding, feedback, and
Semester-long MI coaching
course or
or
Audiotape coding, Feedback from clients
feedback, and coaching Live observation with feedback
Clinical supervision
or and/or peer support Feedback from clients
Live observation with groups; use of videos, MI supervision workshop
feedback role plays MITI/MICA coding workshop
Feedback from clients MI supervision Clinical supervision and/or peer
workshop support groups; use of videos, role
MITI/MICA coding
workshop Visual reminders; plays
success stories Visual reminders; success stories
Refresher trainings; Refresher trainings; new hires
new hires familiar with familiar with MI
MI
Policies and procedures to support
MI use
Training of new (internal) trainers
Implementation teams
MI integrated into specific services
(i.e., intake, case management)

Group or Unit in an Agency

If you are a manager or supervisor and would like your staff to learn and
utilize MI, ideally you all would attend MI trainings. If you have the bud-
get, always an issue, taking MI supervision training will also help you uti-
lize MI in your own coaching and working with your staff. Setting up peer
group supervision or other group supervision where taped interviews with
clients are reviewed and possibly coded (if you have been trained in coding)
can be helpful, once you overcome possible performance anxiety. Some
supervisors have reported using MI videos and role plays with group analy-
sis, discussion, and critique. A study of MI in the workplace gave trainees
(who had completed a 2-day training) 12 weekly worksheets used to ana-
170 IMPLEMENTATION

lyze their own interview tapes, such as by counting the number of complex
reflections. These worksheets were followed up by telephone-based coach-
ing based on observer coding (Bennett et al., 2007).
The MIA-STEP (Motivational Interviewing Assessment–Supervisory
Tools for Enhancing Proficiency) is another model that was developed by
the National Institute on Drug Abuse and SAMHSA to provide substance
abuse treatment agencies with a format to train, integrate, and supervise
MI. (See www.attcnetwork.org/explore/priorityareas/science/blendingini-
tiative/miastep for more information.) This program also contains obser-
vation and self-report forms for supervisors and staff. For the supervisor,
one of the main challenges may be to motivate staff to participate and pro-
vide audiotapes for group supervision. Use of visual tools, such as posters
and bookmarks, can remind staff to use various MI skills, as can hearing
MI success stories. (See https://attcnetwork.org/centers/mountain-plains-
attc/motivational-interviewing-posters for some downloadable posters.)

Agency or Organization
Integrating MI and other EBPs into larger systems of human service work
is difficult, as noted earlier, and it is helpful to become familiar with the
general principles of implementation science as guidelines (Fixsen, Naoom,
Blase, Friedman, & Wallace, 2005). While it is beyond the scope of this
chapter to detail the steps involved in this and other models, much of what
is presented in Table 9.1 is congruent with what this particular line of
research tells us is important in implementing/integrating any change in
practice or skill development.
Administrators at some point make a decision to integrate the use of
MI across many units or levels within their agency. The next step is to
involve supervisors, practitioners, and perhaps clients in a discussion as
to what this might mean in the context of the agency culture, about their
concerns, and to obtain support (Berger et al., 2009). Having had a brief
exposure to MI will help with knowledge of at least what is involved with
this method of communication. The next step would be to plan logistics of
training and involve MI trainers in this process. Questions of who will be
trained, when, and whether it should be mandatory or voluntary should all
be considered. What will be trained is important as well, and a curriculum
to make sure all trainings are uniform will need to be developed (Hohman
et al., 2009).
Trainings are offered and supervisors are trained in the MI supervi-
sion and coaching model. Agencies can solicit feedback from clients and/
or do live observations; the best way to determine whether MI is being
used as designed is to use a fidelity instrument (Fixsen et al., 2005), which
is the MITI or other coding tools. Ideally, staff, or a select group of staff,
provides taped interviews for coding over time, so that they can continue
 Integrating MI into Social Work Practice 171

in their skill development. As in the unit learning plan, peer groups and/
or supervision groups can use role plays and videos for continued learning.
All of these should be supported by policies and procedures that support
this integration, from promoting a culture in the agency that is based on
the spirit of MI to allowing the use of work time for peer group supervision.
As internal trainers are trained in MI, they will allow for continued train-
ing in-house to sustain the skill growth. Implementation teams can provide
structure for many of these changes as well as design how MI skills can be
used specifically in the agency, for example as a part of every intake inter-
view. Bookmarks with MI skills listed or posters can be placed throughout
the agency as visual reminders. Certainly, sharing MI success stories helps
to build the self-efficacy of practitioners in its use. Periodic or refresher
training can be provided and hiring practitioners who can demonstrate MI
through role play or real play will help build sustainability of the integra-
tion.

Proficiency in MI Is Associated with Better Client Outcomes

Crouch and Parrish (2015) described in detail the implementation of MI

in an agency that serves those who are experiencing homelessness. They
noted some of the difficulties of this process: “In addition, at the Interna-
tional Conference on Motivational Interviewing Plenary Presentation in
2012, a description of training efforts provided by Dr. Theresa Moyers
summed up our experience at [our agency] quite well, ‘It is much easier to
get people who are using cocaine to give you data at follow-up than to get
work samples from therapists’ ” (p. 496). In looking at all that is involved
in learning and maintaining MI skills at proficiency level, it is understand-
able to ask: Why all the time and expense to invest in learning any EBP,
including MI?
One interesting finding from an MI training study is that substance
use treatment employees who were randomized to receive MI training as
compared to those who didn’t receive training had lower turnover rates
(Carroll et al., 2006). It is speculated that this may be related to decreased
feelings of burnout reported by those who utilize MI, as discussed in Chap-
ter 1 (Carpenter et al., 2012; Graves et al., 2016; Östlund et al., 2015;
Pollak et al., 2016; Schoener, Madeja, Henderson, Ondersma, & Janisse,
2006). Implementing MI in an agency culture may help retain those who
are in agreement with its client-centered approach. The opposite may hap-
pen if agency culture and practices maintain more of an authoritative focus.
Miller and colleagues (2004) reported anecdotally that the trainees from
their study (some of whom were social workers) indicated that after learn-
ing MI they left their agencies, finding them too in conflict with the spirit
of MI.
172 IMPLEMENTATION

The bottom line is that EBPs are followed to improve client outcomes.
In Chapter 1 it is noted that there are over 1,200 randomized controlled
trials of MI and 180 meta-analyses and systematic reviews of MI applied to
a variety of areas. Systematic reviews/meta-analyses of MI have found (for
the most part) small to medium effect sizes (DiClemente, Corno, Graydon,
Wiprovnick, & Knoblach, 2017; Lundahl, Kunz, Tollefson, Brownell, &
Burke, 2010; Miller & Moyers, 2017). Outcomes can vary by site as well as
by individual therapist, as there is wide variability in learning MI and even
in choosing when to use MI (Wilkins & Whitaker, 2017). One unknown is
what the correct dose of MI is—how many sessions, how much is needed,
and so forth—to affect client change. Practitioners vary, too, in how much
they gain from, say, a 2-day training, and some may speculate that at least
the trainees may have learned a little bit of MI that they can use. Miller
and Rollnick (2013) write that clients getting a little MI (which is what you
might get after one 2-day training) is like saying how good is a dose of a
little vaccine? They advocate that it is better to train and coach practitio-
ners to proficiency, based on individual need, than it is to offer a blanket
number of days of training or training plus coaching sessions.
Proficiency has been found to be related to increased change talk from
clients, and increased change talk is predictive of change. Use of confron-
tation or other methods that elicit sustain talk are related to poorer client
outcomes (Magill et al., 2014; Romano & Peters, 2015). Practitioners can
be trained to reliably and consistently evoke change talk (Moyers, Houck,
Glynn, Hallgren, & Manual, 2017). These technical skills need to be nested
in the ability to demonstrate accurate empathy, establish a change goal tar-
get, and suppress methods that evoke sustain talk (Miller & Rollnick, 2013).

Experiences from the Field

The following are accounts given by this chapter’s two coauthors—social

workers, MINT members, and MI trainers Cristine Urquhart and Fredrik
Eliasson—regarding their work with integrating MI into their agency/
organization practice.

Cristine Urquhart
My interest in MI began in 1996 while I was researching alcohol inter-
ventions during my undergraduate studies. MI aligned with my core
professional values to support people with substance use concerns using
humanity, dignity, and hope as an alternative to all-or-nothing labeling and
shaming approaches. MI influenced many of my educational and profes-
sional decisions. I was fortunate to study and work at institutions where MI
was valued and practiced and made it a focus of my MSW clinical training.
 Integrating MI into Social Work Practice 173

Since becoming a member of MINT in 2007, my understanding and

respect of MI has deepened immensely as a trainer. My primary role over
the last decade has been to offer MI training, coaching, and feedback with
helping professionals. An MI lens as a trainer and coach can help practi-
tioners become aware of their own communication style and resolve their
ambivalence related to practice changes, while supporting organizations as
they strive to align service delivery with core values.
Integrating MI within systems is complex and requires commitment
and vision at all levels. Over the past 5 years, I have been privileged to
work with a children’s hospital and its allied health professionals, support-
ing and strengthening their MI skill development across a range of services
and programs for children, youth, and families. The following shares some
of this story, focusing on organizational decisions, the interprofessional
learning experience, development of MI champions, and MI communities
of practice (MI CoPs).

Organizational Decisions
Before systems change can happen, decisions need to be made on the part
of the organization to integrate an MI approach within their larger vision,
and to decide how to support service delivery across multiple programs and
professional disciplines. It can be helpful when there is some familiarity
with the approach to inform the decision. In this case, the social work dis-
cipline lead, having completed MI training, recognized the value in offering
this approach across allied health and initiated conversations to explore
what might be possible. The organizational rationale for MI was stated by
a discipline lead:

“The organization has adopted a core set of values that serve to

guide clinicians’ actions and interactions with patients, families,
and each other. In adopting a person-centered counselling approach
across a single health authority the values of compassion, account-
ability, respect, excellence, and safety are supported. Motivational
interviewing equips clinicians with a common vernacular and com-
mensurate strategies to support patients and their families who are
experiencing ambivalence in making care decisions. Families can
feel assured that they will receive the same high-quality health care
across clinics and programs. Unnecessary variations in health care
delivery are mitigated.”

Although the ideal, as recommended by implementation science, would

be to have a very involved and multilayered plan at the outset (including
MI CoPs, coaching, supervisor training), this is sometimes where research
and reality move at a different pace. Similar to working with a client, going
174 IMPLEMENTATION

from 0 to 10 is most often too much, too fast. It is the 0 to 1 that can be
the biggest step. In our emerging work together, we first needed to find a
starting point, have professionals experience MI training and see how it
was received. A commitment was made to begin with a 2-day introductory
MI training, followed by a 2-day advanced MI training. At the same time,
seeds were planted in terms of the value of an MI CoP to support ongoing
skill integration and sustainability.
Due to resulting interest and feedback, introductory and advanced
trainings were offered yearly and the MI CoP conversation also evolved.
Leadership recognized the importance of putting structures in place for
ongoing MI skill integration and sustainability, and at the same time
needed some guidance to increase the confidence and clarity of how to pro-
ceed. Two key decisions moved the momentum forward—to establish MI
champions who would then lead the MI CoP development, and to identify
a discipline lead as the link between the leadership and MI champions. The
ongoing question to the champions became “What do you need?” . . . and
their answer: “Time to prepare the MI CoP vision, followed by an invita-
tion to share learnings and hopes with key organizational leadership.”

Interprofessional Learning Experience

Complex health and social concerns require the support of multidisci-
plinary teams to walk with children and families on their care journey.
Allied health within the children’s hospital is represented by many pro-
fessions, including social work, occupational therapy, physiotherapy,
speech–language pathology, audiology, child life, psychology, and family
counseling. Some interactions are brief, and others may have long-term
relationships over the course of a child’s development. Although there
are differences in the specifics of each professional role/program, there
are common themes that resonate across the work, such as importance
of engagement, ambivalence of children/youth/families in making difficult
care decisions or accepting a diagnosis, the role of values, and discord in
relationships. This then necessitates that the teams work collaboratively
with a shared language and approach across professions, both with each
other and with those receiving care.
The training invitation was shared across allied health, and attendance
was voluntary. The interprofessional training format offered opportuni-
ties both to learn more about MI and to strengthen professional linkages
and deepen understanding of each other’s roles. Throughout the learning,
participants shared wisdom and recognized what is already working well,
as well as their vulnerability in refining and practicing MI communication
skills. MI offered a shared spirit in the way of working with each other and
families and brought intent to life through the conversation. Two of the MI
champions stated:
 Integrating MI into Social Work Practice 175

“It’s been rewarding to utilize MI skills and spirit with multidisci-

plinary teams in an environment where we each bring our areas of
specialty; this shared way of communicating with families brings
about a heightened sense of partnership (both as a team and with
the family).”

and

“Engaging with members of other disciplines in small group practice

gives us an appreciation of our differing perspectives, experiences
and insights while allowing us to share a framework and vocabu-
lary to use with our patients/families.”

MI Champion Development and an MI CoP

The research is clear that MI skill development and sustainability requires
ongoing practice and feedback. Ideally, this might be a combination of indi-
vidual and/or group coaching with feedback, as well as an MI CoP to facili-
tate organizational integration across programs and services. The tricky
thing, then, is the resources (time, energy, funds, service delivery logistics,
etc.) to do all of this.
Once the decision was made to support a group of MI champions who
would then lead the MI CoP, the conversation became “What is possible
and how?” MI champions were identified through self-expressed interest
and suggestions from discipline leads across the allied health areas. Each
practice area was represented, with a total of eight MI champions. Leader-
ship provided work time to be involved in the initiative. The MI champion
development involved two streams: (1) MI CoP logistical support, and (2) a
face-to-face integration day of practice activities followed by three virtual
small group coaching and feedback sessions.
Over the course of three, 1-hour monthly conference calls, the MI
CoP logistical support conversations focused on the details of creating a
CoP, such as the vision, role of the champions, activities, content, process,
and ultimately figuring out the first steps of the plan. What became clearer
through the conversations was that the group needed more time to con-
sider what the MI CoP might look like in their unique environment (across
multiple professions and programs with many clinical responsibilities). The
group also need to place value in taking some time to coalesce as an MI
champions CoP first in order to build on their learnings.
The face-to-face integration day and follow-up virtual group coach-
ing (1 hour monthly for 3 months) focused on increasing confidence and
competence as the champions evolved into their own CoP and received spe-
cific feedback on their own practice conversations. The format offered a
framework and ideas of how they might go forward as they continued to
176 IMPLEMENTATION

learn how to learn MI. MI champions also noted the value in offering and
receiving feedback in a supported and safe small group environment and
the importance of additional coaching following larger group trainings for
skill development, as noted below:

“Having Cristine [MI trainer] come in and coach us in small groups

and provide us with feedback gave us an excellent framework from
which to model our own CoP.”

and

“Participating in small group coaching gave us an opportunity to

deepen our practice and skills in MI differently than in a larger
training session.”

So, Where Do We Go from Here?

This is a story of an ever-evolving organizational MI journey. Although the
impact of the multilevel MI training has not been formally funded or stud-
ied, a survey is underway for feedback from participants on the influence
on their practice and hopes for an MI CoP. Anecdotally, I have received
feedback from practitioners who shared that their interactions with fami-
lies have led to positive outcomes as a result of approaching the conversa-
tion differently. With more space for curiosity and empathic listening at
a deeper level, they reported enhanced engagement and reduced discord,
shifting the relationships with families.
The MI champions meet on a monthly basis to practice and illumi-
nate the path forward to expand the MI CoP within the larger group of
allied health professionals across programs and services. They are plan-
ning to offer the first organizationwide MI CoP in the upcoming months.
Another round of introductory and advanced MI 2-day courses are sched-
uled for 2020. MI champions will offer support in the classroom with the
next cohort of learners, thereby continuing to build internal organizational
capacity and motivation.
While research and on-the-ground experiences may differ in pacing, it
is hopeful that after the initial training 5 years ago, MI continues to have
an active presence through the vision and dedication of the MI champions,
discipline leads, and organizational leadership to influence practice change.

Fredrik Eliasson
This is a description of the work of trying to implement MI in an organi-
zation with more than 4,000 employees in 35 different locations that are
 Integrating MI into Social Work Practice 177

spread throughout the country of Sweden. The Swedish National Board of

Institutional Care (Statens Institutionsstyrelse, or SiS) is an independent
Swedish government agency that delivers individually tailored compul-
sory care for young people with psychosocial problems and for adults with
substance use disorders. We provide care and treatment where voluntary
interventions have proved insufficient and care on a compulsory basis is
therefore necessary. SiS runs special residential homes that provide care for
either young people with psychosocial problems, substance use disorders,
and criminal behavior or adults with substance use disorders. The residen-
tial homes run by SiS are the only treatment facilities in Sweden that have
the right to forcibly detain individuals who have been taken into compul-
sory care.
We think of MI as a way of being with people and that MI is the way
we do the things we do in our day-to-day interactions with clients. Our
goal is that the engaging part of MI is always practiced by our staff, with
the aim that the people in our care feel listened to, understood, and valued
as human beings. We are trying to be concrete around how MI can be uti-
lized in the daily practices. One example would be to reduce staff confron-
tational behavior and increase empathy, especially in situations when the
client is upset. An MI-nonadherent example would be:

Client: This place sucks and you just work here for the money!
Staff: It’s not OK to talk to staff in this way. You need to lower your
voice right now!

An MI-adherent reflection of trying to make the client feel understood

might be:

Client: This place sucks and you just work here for the money!
Staff: You are upset. You don’t like it here and you don’t feel like we
that work here really care about you.

More examples of practical interactions could be to use the elicit–

provide–elicit strategy of giving information in an intake procedure or
reduce uninvited advice giving in the daily practice. In conversations about
change we would also work with the processes of engaging, focusing, evok-
ing, and planning.
SiS comes from a long tradition of paternalism and ideals of authori-
tarian parenting with clients (Pelto-Piri et al., 2017). The existing culture
of SiS has a number of behaviors from staff that we would consider to
be MI nonadherent. For many years MI was seen as something used by
the specialists that clients were referred to, but the MI style of being with
178 IMPLEMENTATION

people didn’t influence the day-to-day interactions. For the young people
that lived at the residential homes this made no sense. As one 17-year-old
boy told me:

“Hey, they say you are working with MI! You know, MI seems to be
all right. I have MI conversations once a week with one of the staff.
But it’s all an act. They must have taken some course or whatever
cause they don’t mean anything by it. Don’t get me wrong. I really
like my MI sessions. It’s all about me, what I like to do, why I might
consider changing some of the habits I have and how I see myself
in the future. They are good conversations. But it’s only the staff
being actors because all of the other time, 24/7, they just tell me
what to do all the time and give me a hard time.”

In a confrontational culture, individual change can happen, despite

and not thanks to, staff efforts to be helpful (Gaume, Gmel, Faouzi, &
Daeppen, 2009). The challenge for SiS is to cultivate a new, more person-
centered culture, where it feels natural to support clients’ self-efficacy and
autonomy. SiS is (painstakingly) slowly changing the culture, but the results
are very mixed throughout the country. Some residential homes have come
a long way toward implementing MI and others have not implemented MI
at all.
As for the MI implementation, I currently lead a team of six MI trainers
and MINT members and we are a part of the SiS head office, the Department
for Research and Development. We work nationwide and have designed our
efforts to implement MI around Fixsen et al.’s (2005) theories, which sug-
gest that it’s equally important to address each of the following areas for
successful implementation: competence, leadership, and organization.
In terms of competence, we are working to create an MI training
infrastructure that is suitable for a large organization. We provide a 4-day
foundational/intermediate level training. We emphasize the engagement
process and how the spirit of MI can guide everyday interactions. This
training is mandatory for all staff. About 600 staff take the course each
year. Next is a 3-day advanced training. This is more focused on deepen-
ing the strategic part of MI and includes training on coding with the MITI.
About 120 staff take this course each year. They are often handpicked by
their managers to be a resource at their institution and this is a step on
their path to become certified MI practitioners within the organization.
We provide certification of MI practice. To be certified, staff need to
hand in a work sample that will be coded with the MITI and must pass the
basic skill level. To keep the certification, staff must repeat this every year.
The certified MI practitioners are regarded as a specialist resource at their
workplaces.
 Integrating MI into Social Work Practice 179

We offer a 3-day MI coach training. The focus here is on training MI

coaches who will deliver shorter MI workshops in their own workplaces.
The MI coaches are also trained in implementation science and are part of
the implementation teams in their workplaces. They must be a certified MI
practitioner to apply for the training. About 35 staff take the course each
year. Supervision and support is available for the MI coaches. Each residen-
tial home works with one or more MI coaches. Some of them are members
of MINT or they have undergone training to become MI coaches. They
are responsible for the continuing MI training and supervision of their col-
leagues. We meet with them twice a year at their workplace. SiS has around
100 MI coaches.
Finally, we provide further development training for the MI coaches.
Twice a year we arrange a 2-day training opportunity for them. This is a
way to further enhance their understanding of MI, networking, and prac-
tice in the role of MI coach. We hope that the combination of our different
workshops and the continuing MI training that the MI coaches facilitate
will help gradually build fidelity to MI.
As for the focus on leadership, we meet with each of leadership team
of the residential homes twice a year and offer support around implemen-
tation and leadership. We mainly aid them by (1) giving short workshops
about implementation and leadership science, (2) helping them form imple-
mentation teams and make an implementation plan, and (3) helping them
to be concrete around how MI can be utilized in the daily practices.
Leadership support and engagement in the implementation process is
of vital importance. The need for transformational leadership is even more
significant when working toward a shift in the work culture. An example of
leadership impact is when the leader is skillful in creating an implementa-
tion climate by communicating the expectations of using MI, following up
to see that it is practiced with fidelity, offering continuing support to staff
who try to learn and gain proficiency, and rewarding staff by giving recog-
nition and appreciation when they use MI in their daily practice.
As for organizational support, there are a few things in place that are
helpful factors for implementation, such as the basic mandatory MI train-
ing. SiS has funding for a central team of MI trainers and SiS supports
achieving fidelity of MI by certifying MI practitioners. Unfortunately, there
are no extra benefits for employees who have the certificate. If there were,
it would probably be a helping factor for implementation. While there are
many supports, SiS has a long tradition and culture of each residential
home deciding for themselves how to run their own operation. This makes
broad implementation of EBPs like MI difficult.
It has, however, been rewarding for me to work on the MI team. SiS
provides care and support to some of the most vulnerable people in Sweden.
They are individuals who in many cases have a long history of being treated
180 IMPLEMENTATION

with a judgmental, overtly directive, and sometimes abusive response to

their needs. To be part of a movement that tries to change the culture of
SiS away from its old traditions and toward a more person-centered way
of treating people in our care is deeply meaningful. It will, in my opinion,
alleviate some of the suffering our clients experience and make it more
likely that they will make changes in their lives: changes that increase the
likelihood that the people will live more fulfilling lives, not despite of, but
because of the treatment they got during their time with SiS.

Final Thoughts

As seen from research and in these implementation stories, learning and

using MI is difficult but can be a rewarding process, especially when social
workers see clients’ responses and positive outcomes. Because it is expen-
sive to train, observe, and coach social workers to proficiency, there is a
need for cost-effectiveness studies regarding training as well as continued
work on technology-based methods that can be more efficient (Madson,
Schumacher, Baer, & Martino, 2016). Miller and Moyers (2017) write that
perhaps the focus should be on the next generation of trainees and students
who come to agencies already prepared to work in a client-centered man-
ner, if not proficient in MI. Local agencies sometimes post MI as part of the
job requirements and it is hoped that these beginning practitioners enter the
field equipped with MI skills that are enhanced and continually supported
in their work settings.

EPAS Discussion Questions

EPAS 4: Engage in Practice-Informed Research and Research-Informed Practice

 Use and translate research evidence to inform practice, policy, and service
delivery.

1. In reviewing the research on training and implementing MI on

an individual level, what would you need to do to increase your
skills?
2. What would your agency/internship site need to do to bring all
social workers to proficiency level?
 C hapte r 10

Motivational Interviewing through

the Lens of Critical Race Theory

EPAS 2: Engage Diversity and Difference in Practice

 Apply and communicate understanding of the importance of
diversity and difference in shaping life experiences in practice at
the micro, mezzo, and macro levels.
 Present themselves as learners and engage clients and
constituencies as experts of their own experiences.
 Apply self-awareness and self-regulation to manage the influence
of personal biases and values in working with diverse clients and
constituencies. (CSWE, 2015, p. 7)

Usually when social workers or social work students are learning MI, the
focus is specific regarding its practice behaviors, to the point that learning
involves doing sentence-by-sentence analyses of practitioner statements as
fidelity measures, as discussed in Chapter 9. The chapters in this book fol-
low this format by presenting the four processes, spirit, and skills, with
simple coding of the case vignette examples. But as social workers who
work with diverse clients, we all also need to have MI conversations based
on the mezzo and macro contexts in which we (including clients) all live.
What is the bigger picture in your work with clients and how you practice
MI? What is the best way to interweave these contexts into your MI con-
versations?
About 2 years ago I had the opportunity to conduct a workshop
for graduate social work students on MI and cultural humility, which is

181
182 IMPLEMENTATION

described later in this chapter. As part of the workshop we watched a video

that provided a good demonstration of MI skills: the interviewer used lots
of OARS, permission/autonomy support, and the change ruler. The whole
interchange was respectful and supportive. The patient was an African
American woman (however, it was never mentioned; she could have been,
for instance, Caribbean, African, or Latinx), and the interviewer was a
White male physician in a lab coat. The target behavior/goal was to identify
actions to address her depression. The patient seemed subdued but rela-
tively engaged with the physician, and he worked to elicit her perspectives
and ideas. She quickly shut down the idea of medication and he didn’t
argue with her but moved on to finish with a plan that she created around
exercise. After the video was over, we discussed the details of the doc-
tor’s MI skills, but then took a broader view when I asked the following
questions: What was the power imbalance in the room? How might that
have influenced the conversation? How might race have affected the inter-
action? What are some of the views of mental health treatment as well as
medication use in the African American community? How might they have
impacted the interview? If the doctor were to ask about them, might this be
eliciting sustain talk, which isn’t helpful? What is the role of experienced
discrimination in mental health? Should race have been discussed at all? If
so, what might that conversation look like?
The goal of this chapter is to begin to answer these and similar ques-
tions. Using the EPAS (CSWE, 2015) competencies at the beginning of this
chapter, I will begin to unpack how exactly social workers might “com-
municate . . . understanding of diversity and difference” when using MI
skills as well as how to present ourselves as learners of clients’ diversity
experiences (CSWE, 2015, p. 7). I will focus on thinking about personal or
implicit biases and how they may affect social work practice. It should be
noted that I am writing this from the perspective of a White woman with
some of the content aimed at White social workers; many social workers
who are people of color may already be well familiar with biases; many may
have experienced them in their own lives. I will use the lens of critical race
theory (CRT) (defined below) with examples of how the MI practitioner
can use this theory to have some challenging but productive conversations
that may include topics at the micro as well as mezzo and macro levels.
Why should you make an effort to focus on diversity and difference?
Isn’t just being an MI practitioner enough? The answer is: maybe. As noted
in Chapter 1, MI has crossed cultures both in its dissemination interna-
tionally and through its effectiveness, as found in research studies. MI’s
emphasis on curiosity and on being nonjudgmental, empathetic, respect-
ful of autonomy, and compassionate in many ways provides what Miller
(2019) proposes is a contrast effect to what clients who are people of color
may have experienced previously with social workers/therapists/physicians.
 MI through the Lens of Critical Race Theory 183

Of course, this contrast effect may also be true for clients who are LGBTQ,
differently abled, women, religious minorities, or anyone who has experi-
enced discrimination from professionals or just in everyday life. Most peo-
ple respond well to being accepted, respected, and treated as competent,
which is central to MI (Tsai & Seballos-Llena, 2019). Not explicitly com-
municating the importance of race (or other diverse identities), however,
ignores a central component in many clients’ lives.
There are multiple intervention studies of how MI has been adapted to
make it even more culturally relevant, as noted in Chapter 1. These stud-
ies may incorporate specific cultural values, languages, foods, and/or cus-
toms, for example, which are all ways to acknowledge the cultures or social
contexts of people of color. A recent systematic review of 61 culturally
adapted MI studies found that these adaptations led to positive outcomes
for most clients. Other adaptations noted in this review were discussions of
immigration difficulties, discrimination, historical trauma, and psychoso-
cial barriers; ethnic matching between therapists and clients; and cultural
education of the therapists (Bahafzallah, Hayden, Bouchal, Singh, & King-
Shier, 2019). These adaptations are examples of how to address the EPAS
competency about communicating the importance of diversity. One study
asked clients for feedback about how they experienced a culturally adapted
intervention. Latinx clients who received a brief MI intervention regarding
heavy drinking indicated that their discussions with the therapists regard-
ing their cultural perspectives, immigration experiences, and social con-
texts of drinking were particularly helpful (Lee et al., 2011). You may need,
then, to go beyond just practicing regular MI if you want to communicate
the importance of diversity and difference in your clients’ lives.

CRT and Social Work

Race, as noted above, is just one area of difference and diversity but is the
focus of this chapter. Dr. Larry Davis, a former dean of social work, has
stated that race and racial discrimination often get subsumed in discussions
of diversity but are “America’s postponed grand challenge” in terms of the
social problems and inequities that clients face and social workers address
(Davis, 2016, pp. 397–398). The Grand Challenges for Social Work (Fong,
Lubben, & Barth, 2018) is a roadmap for social work policy, practice, and
research for social problems, such as homelessness, social isolation, and
family violence, and is discussed in Chapter 12. People of color are dispro-
portionally affected by these social problems that are fueled by “a major
engine of color-blind racial attitudes, behaviors, and beliefs” (Constance-
Huggins & Davis, 2017, p. 105). Race-based social problems include dis-
criminatory policies and practices in housing and labor, voter suppression,
184 IMPLEMENTATION

public school segregation, health disparities from birth throughout the

lifespan, the school-to-prison pipeline, mass incarceration, violence from
police, and poverty, among others (Alexander, 2012; Davis, 2016; Jeffers,
2019; Lawson-Borders, 2019; Whitaker, 2019). Racism is a chronic social
stressor and has been linked to poor health, risk for chronic illnesses, and
mental health problems (Thames, Irwin, Breen, & Cole, 2019).
CRT was developed in legal studies to examine racial inequities in
our culture that are due to policies and laws (Delgado & Stefancic, 2017).
It provides a framework to think about race, racism, power, and social
change. It is also useful for social work practice, including how social
workers can communicate about these topics with clients, hear their voices,
reflect on their own biases and values, and address discriminatory policies
at the agency or governmental level (Abrams & Moio, 2009; Kolivoski,
Weaver, & Constance-Huggins, 2014). CRT has five or six different tenets
(depending on the author). I will look at three of them that are the most
pertinent to the MI practitioner.
The first tenet of CRT is that racism is normal or ordinary in Ameri-
can society (Delgado & Stefancic, 2017; Kolivosk et al., 2014; Trahan &
Lemberger, 2014). You only need to read the daily news to learn about
racist remarks, actions, or violent incidents. As a social worker, you may
not think of yourself as racist and you may believe that you would never
do anything like what you read about. Social workers do, however, need to
recognize that racism is systemic, and typically we all participate in these
racist systems. It is threaded throughout institutions, social structures, and
policies. Institutional racism is built to privilege those who are White, and
for those who are White, systemic racism is usually not even recognized
(Oluo, 2018). While it is beyond the scope of this chapter to examine what
these social structures and policies are, they explain the larger disparities
in health, education, employment, and criminal justice that are experi-
enced by people of color. It is incumbent on social workers to recognize
and address policies and practices in work settings or laws that are racist
and/or discriminatory. A school social worker, for instance, may challenge
practices that disproportionally suspend male students who are African
American. The NASW (2015) Standards and Indicators for Cultural Com-
petence in Social Work Practice state:

Standard 6: Empowerment and Advocacy. Social workers shall be aware

of the impact of social systems, policies, practices, and programs on
multicultural client populations, advocating for, with, and on behalf of
multicultural clients and client populations whenever appropriate. Social
workers should also participate in the development and implementation
of policies and practices that empower and advocate for marginalized and
oppressed populations. (p. 35)
 MI through the Lens of Critical Race Theory 185

Because social workers and others are surrounded by racist social

structures, policies, and media, as well as social media messages, it is
impossible to not indirectly take them in, leading to what is called implicit
bias (Lawson-Borders, 2019). Implicit bias is defined as “actions or judg-
ments that are under control of automatically activated evaluation, with-
out the performer’s awareness of that causation” (Greenwald, McGhee, &
Schwartz, 1998, p. 1464). In other words, implicit biases are attitudes and
even actions that are outside of your consciousness and can be uninten-
tional (Bruster, Lane, & Smith, 2019). Beyond race, implicit biases may
be held about gender, gender identity, sexual orientation, religion, ability
status, age, immigration status, mental health, skin color, and/or body type
(Kopera et al., 2015; Maina, Belton, Ginzberg, Singh, & Johnson, 2018;
Montalvo, 2009).
Implicit bias can lead in turn to stereotyping and microaggressions,
which are everyday remarks or behaviors that “send denigrating messages
to a target group” (Sue et al., 2019, p. 122), and they are often invisible
to those who commit them. A study of microaggressions in cross-racial
counseling settings identified many different examples: being color-blind,
or not addressing the client’s race; presuming that racism was not an issue
for the client; assuming that the client had a certain characteristic or trait
due to their race; and minimizing the importance of the client’s culture;
among others (Constantine, 2007). Another study of clients of color in a
community-based mental health setting found that 81% reported at least
one microaggression from their therapist (Hook et al., 2016). Unsurpris-
ingly, microaggressions in counseling predict early termination (Owen,
Tao, & Rodolfa, 2010).
Another tenet of CRT is a critique of liberalism (Delgado & Stefancic,
2017; Kolivoski et al., 2014). The critique is of liberal ideas that include the
following: humans are all the same, everyone should be treated equally,
everyone should be color-blind, everyone experiences the world the same
way, people have equal opportunities and access to resources, and laws
are neutral and are fairly applied. These ideas fail to recognize systemic
racism and its impacts on people of color. This is essentially a denial that
discrimination exists. The physician in the video described at the begin-
ning of this chapter, while well intentioned, may not have even thought
about the role of discrimination/racism in the life of his patient and how
that may be impacting her mental health (Kolvioski et al., 2014). Further,
he may not even have considered the intersectionality of her cultural identi-
ties, of being African American and female, and what that might mean to
her in terms of her seeking and receiving help for mental illness (Crenshaw,
1995; Lewis, Williams, Peppers, & Gadson, 2017). As noted above, ignor-
ing these aspects of clients’ lives can be interpreted as microaggressions.
Ignoring these aspects isn’t done purposefully but often stems from the
186 IMPLEMENTATION

fact that White professionals have the privilege to not have to consider or
think about these topics in their own lives, much less those of their clients
(Constance-Huggins & Davis, 2017; Trahan & Lemberger, 2014). Sue and
colleagues (2019) indicate that those who are White counselors (or social
workers) may not want to hear clients’ stories of discrimination, as it is
hard to reconcile the racism and suffering, along with their own participa-
tion in racist systems, and still see themselves as good and caring people.
A third tenet of CRT is the importance of the counternarrative or sto-
rytelling, whereby the experiential knowledge of discrimination and racism
is encouraged to be told and used to both empower people of color and
challenge racist beliefs, thoughts, and policies (Delgado & Stefancic, 2017;
Kolivoski et al., 2014). People of color are often silenced, have their experi-
ences minimized by being told to quit using race as an excuse, or are told
they are overreacting or that all of their problems are due to their own char-
acter (Sue et al., 2019). This is due to systemic racism that does not want to
yield power and wants to maintain a color-blind stance where racism is not
acknowledged (Abrams & Moio, 2009).

CRT and MI

What does the above information on CRT mean for the MI practitioner? I
will look at practice implications but first I will examine how CRT and MI
were used in an intervention research study as an example.
In the first phase of this program of research, a project called Heart
to Heart 1 (HTH1), developed and tested a multicomponent interven-
tion to address the problem of low rates of antiretroviral therapy (ART)
uptake and adherence, and poor engagement in HIV care among African
American and Latinx adults living with HIV. The HTH1 intervention was
grounded in CRT and self-determination theory, with MI as the counsel-
ing style used throughout the various intervention components (Gwadz et
al., 2015). CRT informed the intervention, as described below, including
incorporating recognition of the structural, social, cultural, and personal
barriers that the participants faced in engaging with the health care system
to address their HIV diagnosis, and by actively eliciting perspectives on
these barriers, and potential solutions, during the intervention activities.
Participants (N = 95) were recruited from community-based clinics and
HIV service organizations and through peer-to-peer methods. All had been
living with HIV for 6 months or more and had no or only sporadic ART
use in the recent period. Participants were randomly assigned to receive
the HTH1 intervention or treatment as usual, which served as a control.
Participants randomly assigned to the HTH1 intervention received four MI
one-to-one counseling sessions that lasted 60–90 minutes each, with one
 MI through the Lens of Critical Race Theory 187

I find myself lost sometimes when working with my clients. There are
some very real and powerful societal forces that push, pull, and shape us.
Concepts such as structural oppression can seem abstract in an educational
environment, but as social workers in the field, we have an up close look at
systemic inequity and its affects in communities, families, and individuals.
The existing power structure privileges me as a White man as it interrogates,
excludes, and marginalizes many of those I work with. What is my part
in this? How have I contributed to these systems, and what actions
should I take? This thought process can amplify my feelings of anxiety
and powerlessness. Ultimately these thoughts can act to create emotional
distance between myself and those I work with. Privilege can be a barrier to
my compassion.
I live in a city named the most racially segregated city in the United
States. I work in the mental health field with a largely African American
population. The approaches offered by cultural humility (CH) and MI
invite me to take action or at least be authentically present with the folks
with whom I work and live. I can avoid playing the part of the expert, and
instead seek to learn from those with whom I work. I can name and address
the power dynamics that I notice in relationships and in larger society. I can
seek out opportunities to engage with diversity and difference in my life and
in my work.
As an intake coordinator I work with clients at the beginning of
their treatment. They often initially present with frustration regarding
obtaining basic resources such as housing, income benefits, or employment
opportunities, especially when obtaining them is thwarted by systemic racist
policies or practices. These instances provide me opportunities to engage
in conversations about culture, difference, and related power dynamics. A
client might say, “I’m a Black man who needs a place to stay and food to
eat. No one cares about me and my family, if I were White it would be a
different story. Now you are telling me that I need to do more paperwork,
when what I really need is help.” Before responding, it is important for me
to avoid shutting down or taking the statement as a personal attack. I need
to step back and acknowledge the truth and feelings inherent in the client’s
statement, which allows me to provide a more helpful response. I might
say something like, “You have a lot of needs right now, that is why you are
reaching out for help. I don’t know what it is like to live as a Black man in
this city. You have experienced some powerful discrimination.” A reflection
such as this can serve as a microaffirmation of one’s experience in an
inequitable system. By resisting the righting reflex and validating the client’s
identity-related experience, this reflection acknowledges inherent power
dynamics and leaves the conversation open for the client to elaborate more,
if he chooses.
                           (continued)
188 IMPLEMENTATION

The practices of CH and MI invite us to connect in an authentic and

respectful way by valuing differences and honoring common humanity and
by acknowledging and addressing inequitable power dynamics. MI and CH
provide me guidance in working to become a stronger collaborator, social
worker, and critical thinker in my behaviors.

         Jesse Jonesberg, MSW, LCSW

         Mental health professional and intake coordinator
         Milwaukee, Wisconsin

session attended by a support person. They then received navigation (case

management) for 12–24 weeks and concurrent focused support groups for
five sessions. All participants were matched with a peer mentor, namely, an
individual who was also living with HIV, had struggled with similar types
of barriers to ART, but who was currently taking ART with high levels of
adherence and engaging in HIV care at recommended levels (Gwadz et al.,
2015).
The individual sessions were conducted by a social worker who is a
member of MINT and identifies as White. She trained the peer mentors in
MI (E. Silverman, personal communication, November 1, 2019). The indi-
vidual MI sessions were manual-based with the following goals: (1) under-
stand the participant’s history with attitudes toward and relationship with
medical institutions and medical providers, explore emotions related to
engaging in HIV care and taking ART, unpack barriers of and facilitators
to HIV medical care and ART, assess readiness to engage in care or take
ART using the readiness ruler; (2) explore the pros and cons of engaging in
HIV care and taking ART, if appropriate; (3) understand the significance
of HIV medication side effects, as well as how substance use and men-
tal health affect HIV treatment and ART adherence; and (4) if appropri-
ate, discuss adherence strategies and solutions, review HIV care and HIV
medication goals, and discuss the importance of social support in achieving
stated goals. Videos, infographics, and other handouts supplemented the
MI conversations and introduced race-related concepts (medical discrimi-
nation, distrust, judgment, stigma, etc.). Sessions were individualized to the
needs identified by the participant (HTH manual, 2017).
Respecting and encouraging autonomy played a significant role in
these sessions. This was particularly important because autonomy is rou-
tinely disregarded or not supported within medical systems for people of
color. Thus, supporting autonomy can be a powerful motivator for change.
Similarly, the opportunity to explore opposing health beliefs in these ses-
sions, such as the desire for good health contrasted with the reluctance to
take HIV medication that can improve health, and have these discrepancies
 MI through the Lens of Critical Race Theory 189

validated and elaborated upon, was a unique experience for participants,

who reported they are generally told they should take ART, and enabled
movement toward change (HTH manual, 2017).
The conversations in the MI sessions, besides autonomy support,
included a focus on past successes and strengths to motivate current behav-
ior change, OARS skills, change rulers, elicit–provide–elicit (E-P-E) meth-
ods to provide information about HIV care and ART medication, and plan-
ning (Gwadz et al., 2017). What might be considered sustain talk, that is,
barriers to care, were specifically elicited to understand and also acknowl-
edge what the participants contend with as they seek to access HIV care.
Sessions were audiotaped for MITI coding by an outside expert (HTH
manual, 2017).
The tenets of CRT were addressed using MI spirit and skills as the
style of communication.

Racism as Ordinary
The intervention included eliciting or evoking environmental/structural
barriers as well as supports that the participants faced in navigating the
health care system, particularly HIV care and ART medication use. This
acknowledged the racism and discrimination that affected them, including
unequal access to resources, discriminatory policies, and issues with hous-
ing and employment practices. Centering the participant as an expert in
their experiences, especially their experiences of racism, acknowledged the
existence of racism as an ordinary aspect of society and gave voice to the
ways daily racism affected health and health behaviors. Systemic racism is
maintained by its invisibility and silence; asking participants to bring it into
the light and name it is a crucial first step in challenging it.
One goal of the intervention was to deliberately recognize the par-
ticipants’ sociocultural location, defined however they chose, which was
usually race and/or class. This was initiated with a question from the social
worker about how culture plays a role in how people think about health
care, HIV care, and ART medication. She also specifically introduced the
common experience of medical distrust related to race-based histories of
medication experimentation, and stigma, as well as personal experiences
of not being treated equally or respected. It was often the responsibility of
the social worker to take some initiative in recognizing the racial dynamics
of the social worker–client interaction, which included historical racism,
and give clients the opportunity to react to those concepts. Some partici-
pants took the opportunity to express their experiences of racism and some
shifted to a different topic. Intersectionality was also important to identify
how participants’ views on health care and HIV care might be affected
through the overlap, say, of being transgender along with living with HIV
190 IMPLEMENTATION

(Freeman et al., 2017; HTH manual, 2017). Many felt that because of their
race and class they received lower quality of care. One participant, when
asked about previous health care experiences, stated:

I think mostly it’s pains that mostly people of color go through. You know
it’s a lot of pains. It’s a lot of rejection. Not understanding the person’s,
you know, history or what the person’s been through, and trying to find
someone that really cares to listen to that person. You don’t get much
of that because they tell you, ‘I don’t have time because I have 50 other
thousand people that have worse situations that you,’ and so you walk out
bitter. . . . So a lot of people—okay, a lot of African Americans—they are
on that pre-judgment. (Freeman et al., 2017, p. 6)

Voicing the Counternarrative

The elicitation of participants’ stories provided opportunities to expose rac-
ism as embedded in social structures and critique liberal bias, as described
above, but also provided a space to voice and validate counternarratives.
The participants’ stories were elicited in the MI sessions in order to under-
stand them and their perspectives on the target behaviors. Some of the
counternarratives that participants described, besides their encounters with
the health care system, included that HIV was man-made specifically to
destroy the gay and/or Black communities and that the cure for HIV was
being withheld from them because they were poor (Freeman et al., 2017).
Factual information about HIV care and ART medication was only pro-
vided if it could be helpful for a specific gap in the participants’ knowledge,
but only after the social worker asked permission to do so. As noted above,
along with structural barriers, the social worker asked about social and
individual barriers and supports to HIV care and to taking HIV medica-
tion. The participants were also asked about their values, past successes,
personal goals, strengths around health care, hope around participating in
the sessions, and comorbid conditions. Ambivalence was recognized; that
is, participants expressed wanting to be well versus dehumanizing experi-
ences they had felt, particularly with the health care system. Sometimes the
participants labeled these experiences as invisible, in that the individual
health care provider may have been well-meaning, but the overall system or
facility had many structural barriers, such as location, long waits, or other
problems with access. Other times health care providers were experienced
as paternalistic, with their expertise privileged over the participants’ own
lived experiences and abilities to make the best decisions for themselves
(Freeman et al., 2017).
The HTH1 intervention is an example of utilizing CRT as a frame-
work for MI conversations to understand the experiences of the partici-
 MI through the Lens of Critical Race Theory 191

pants, including their incidents with structural and interpersonal racism,

which underpinned many of their decisions to avoid the health care system
and HIV medication. The intervention in itself could not change structural
barriers that are based on race or poverty but used a micro method of
interpersonal counseling (as well as other mezzo methods) to understand
how these macro issues impact clients and their perspectives on the target
behaviors. Participants were assisted through navigation in how to circum-
vent their identified barriers to access housing, insurance, or medical care.
It should be noted that, at the posttest follow-up, the study found a large
effect size regarding medication initiation and adherence and reduced viral
loads in the intervention group, as compared to those in the control group
(Gwadz et al., 2015). Currently, a study is underway to determine which of
the various components of what is now HTH2 contribute the most to the
positive outcomes and which are more moderators of its efficacy (Gwadz
et al., 2017).

Implications for MI Practice

Using the HTH1 intervention as an example, I will expand it to explore

how, as social workers and social work students, you can use CRT as a
framework for your MI practice. For some, CRT’s tenets may be difficult,
and I appreciate the possible struggle to really take in its meanings. If you are
White, it can be uncomfortable to think about racism in your daily culture,
or even in your social work practice settings, not to mention how to discuss
it with clients. The emphasis of CRT on social justice, however, makes it a
good fit for social work and the standards for cultural competence written
by NASW (Abrams & Moio, 2009; Kolivoski et al., 2014; NASW, 2015).
How can CRT be utilized to focus on issues of race, when necessary, to
engage clients; acknowledge their diversity, difference, and intersectional-
ity; center their experiences; and be self-aware and self-regulate your own
biases? How you approach and interact with clients using MI can fit rather
seamlessly with the tenets of CRT, as the HTH intervention demonstrates.
A broader view can help.

Racism as Ordinary
For some reading this book, including social workers of color, this tenet of
CRT is a given. You experience racism and discrimination in your personal
lives as well as in the lives of your clients. Perhaps if you are White, you may
be unsure, or are confused about structural racism. It might be helpful to
do some research and read about racial disparities in your area of practice,
whether it is health, mental health, criminal justice, child welfare, educa-
192 IMPLEMENTATION

tion, and the like, and think through why these disparities might be. What
do you see in the context of where you work or are doing your internship?
Are there policies or practices that might somehow be unfair to clients of
color? Ask your clients about their experiences with the agency or school,
and talk to your coworkers about what they see regarding discrimination
toward clients. Seek out colleagues who are people of color and ask permis-
sion to ask them about their experiences. They may not want to share them,
but many often will. Read about White privilege and think about how it
may impact your work. Consider advocating for policy changes in your
work setting or community, based on all you have learned. Racism remains
ordinary when we are silent about it.

Critique of Liberal Bias

Discussions of experienced racism and discrimination with colleagues and
clients can help to address color blindness. White social workers may think
colleagues of color experience the job the same way they do, when in many
ways they might not. They may feel their voice is not considered in meet-
ings, they are passed over for promotion, discussions of race are discounted
in supervision, or they are paid less than their White colleagues (Lipscomb
& Ashley, 2017). Their clients may question them or even make racist com-
ments. Lee (2010), who identifies as Asian American, writes that, “I have
often come across clients who use my race and ethnicity . . . in order to
engage me, challenge my credentials, or test my clinical capacities to work
with them” (p. 277).
You may think clients who are people of color experience social work-
ers in the same way, in that the race of the social worker shouldn’t matter.
One time, in a training I was conducting with child welfare social workers,
we were practicing how to respond to statements of discord. As we went
around the room, giving (hypothetical) client statements with (hopefully)
good MI replies, when it was my turn, a woman who was African Ameri-
can and a supervisor looked at me and said, with a sigh, “Oh great, another
White woman!” I was a bit taken aback, but appreciated the example she
was providing. I responded to her, “It sounds like you have had some bad
experiences with other White social workers.” She nodded yes, that this
was true. Because it was just an exercise, we didn’t have time for any fur-
ther discussion, which could have been fruitful in another context. Interac-
tions such as this and what Lee (2010) describes above as reactions to her as
an Asian American could be considered discord in MI. The comment from
my role play example could stem from anticipated discrimination. Reac-
tance theory could also trigger such a statement and is discussed further
below in the case vignette.
Hesitancy to engage, particularly with a White social worker, may be a
 MI through the Lens of Critical Race Theory 193

survival mechanism (Trahan & Lemberger, 2014). Making comments to a

social worker of color about race or qualifications may be more of a micro-
aggression, particularly if it came from a White client. No matter how these
are labeled, they are difficult to hear from clients. Lee (2010) notes, “If the
client has previous negative experiences with the clinician’s cultural group,
the client may respond to the clinician in a negative manner, which in turn
can evoke negative complementary behavior from the clinician, consciously
or unconsciously” (p. 277). In MI, you self-regulate, consider where the
client statements might be coming from, remember CRT and reactance the-
ory, and perhaps give a complex reflection about what you think the client
is trying to say, or use other discord strategies as described in Chapter 6.
While it might be easy to do so, you don’t want to respond to discord with
more discord.
Recognizing your own implicit biases is another way to not be color-
blind. Everyone has unconscious biases, and to begin to address them, they
should not be repressed but acknowledged (Bruster et al., 2019). One way
to identify your biases is to take the implicit association tests that can be
found at: https://implicit.harvard.edu/implicit/. Spending time with people
of color, or people who are different from yourself in other areas besides
race, is a way to learn more, but it is your job to teach yourself and not the
job of people of color to teach you (Halloway, 2015). Read novels or non-
fiction by people of color, attend cultural celebrations, attend continuing
education, and/or follow along in social media such as #nativetwitter and
#blacklivesmatter, but only as a window into what others think or experi-
ence (Davis et al., 2016). Kendi (2019) and Sue and colleagues (2019) chal-
lenge people to become not just nonracist but antiracist in terms of actively
working to promote racial equity through advocating for fair policies and
practices.
Cultural competency is essential in social work practice in terms of
learning about the values, practices, experiences, and strengths of groups
that are different from our own, as well as identifying agency policies and
practice behaviors to work more effectively with diverse clients (NASW,
2015). One emphasis in cultural competency is that social workers should
have a knowledge base of the cultural groups they serve, although how that
knowledge can be used isn’t always specified, and practitioners should be
careful of stereotyping (Lee, 2010). Specific knowledge could be applied,
carefully, through the use of MI skills such as open-ended questions and
reflective listening. For instance, in the video discussed at the beginning of
this chapter, the physician and client discussed exercise as a step to help with
her depression. An important barrier to exercise that has been identified by
African American women is hair maintenance and how to manage this due
to perspiration and the time and expense needed for restyling. It is recom-
mended that physicians be able to discuss hair maintenance methods in
194 IMPLEMENTATION

this context (Tolliver, Hefner, Tolliver, & McDougle, 2019). While I don’t
know about the physician’s cultural knowledge base, had he discussed hair
care management with his patient, the likelihood of her following through
on exercising would most likely have increased. He had never, however,
acknowledged that she was African American, so it is hard to tell how this
important issue would have been raised. Thus, having a color-blind inter-
action may not provide opportunities to discuss important cultural issues
as they impact the target behavior. Perhaps hair maintenance would not
have been a concern for the patient, and it can’t be assumed that it would
be; however, she probably would have appreciated that it was brought up.
Another way to address color blindness/unconscious bias is through
the concept and behaviors of microaffirmations. Rowe (2008) proposed
microaffirmations as behaviors that are intentional to counter microaggres-
sions that people of color, women, religious minorities, LGBTQ, and others
who are marginalized may receive, such as being talked over, ignored, or
stereotyped. Her work was based in the university setting where she saw
people of color, especially, not introduced in either professional or social
settings, not given fair assignments, or having unrealistic expectations
placed on them. She defines microaffirmations as “apparently small acts,
which are often ephemeral and hard-to-see, events that are public and pri-
vate, often unconscious but very effective, which occur whenever people
wish to help others succeed” (Rowe, 2008, p. 4). This means that you pay
attention to your own unconscious bias and to what is happening to the
other people/colleagues you may interact with, particularly in the work set-
ting. These behaviors can include highlighting what the other person has
said or contributed in a meeting, not being the first to speak or voice an
opinion, giving a full-blown MI affirmation, and other gestures to signify
inclusion and worth.

Voicing the Counternarrative

Cultural Humility
Cultural competency in and of itself might not be enough in that each indi-
vidual experiences their culture differently, plus there is an unending list of
different cultural groups with variations in each (Ortega & Faller, 2011).
Because you can’t know everything about every type of client you serve,
the concept of cultural humility was designed to address the limitations
of practitioner knowledge. It was developed initially for training of physi-
cians (Tervalon & Murray-Garcia, 1998) and has been embraced by social
workers (Ortega & Faller, 2011; Schuldberg et al., 2012). Humility is about
recognizing and accepting one’s limitations as to understanding others’ cul-
tures and being willing to learn from the individual patient or client. Like
 MI through the Lens of Critical Race Theory 195

the spirit of MI, this stance frees social workers from having to be experts
and is a life-long process of learning from clients (Miller & Rollnick, 2013;
Ortega & Faller, 2011). Perhaps in the example given above, the physician
could have said to the client, “Often hair care maintenance is a concern for
women when they exercise. While I am not an expert on this topic, I am
wondering how, if at all, this might be a concern for you?” The humility is
demonstrated through raising a possible concern, being curious as to the
client’s thoughts, being open to her response, coming from a not-knowing
and nonexpert stance, and not assuming that this is a concern for her spe-
cifically. Table 10.1 demonstrates how similar cultural humility and MI
are, with the exception of the explicit focus on self-reflection and critique
in practicing cultural humility, regarding one’s biases, values, or attitudes.
MI inherently voices the counternarrative by eliciting and carefully
listening to clients’ stories and perspectives. The HTH1 intervention inten-
tionally asked about experienced racism and structural discrimination that
were barriers to HIV care. Should the MI practitioner discuss race and
racism with clients? Again, the answer is maybe. It would depend on the
context and the length of time the social worker has to meet with a cli-
ent. There could potentially be two different types of conversations: your
clients’ experiences with racism or other identity aspects as they relate to
their target behavior, and discussing your cross-racial differences with your
clients. Either way, before you begin any type of discussion, and to avoid

TABLE 10.1. Cultural Humility and the MI Spirit

Cultural humility MI spirit
Interpersonal Interpersonal
Openness Acceptance
Nonjudgmental Nonjudgmental
Respect Respect
Curious/not-knowing stance Curious/not-knowing stance
Clients’ perspectives are centered Clients’ perspectives are centered
Honors client autonomy Honors client autonomy
Partnership/clients as capable Partnership/collaboration/clients as
Egoless capable
Intersectionality Evocation
Self-awareness Compassion
Self-reflection and critique Accurate empathy
Institutional accountability Autonomy support
Ongoing learning/lifelong practice Ongoing learning/lifelong practice

“A way of being . . . ” (Foronda, “A way of being . . . ” (Miller &

Reinholdt, & Ousman, 2016) Rollnick, 2013)
196 IMPLEMENTATION

microaggressions and stereotypes, it helps to have come to some under-

standing of the first two tenets of CRT: that racism is systemic and that
none of us can be color-blind, thinking that everyone experiences the world
in the same way.

Cultural Conversations
When you discuss race or any other identity with clients, first you engage
with them and support their autonomy. It is up to them to decide if this is
something they want to talk about, and if so, what cultural identities are
most salient to them (Berg, 2015; Owen et al., 2016). In the HTH1 study,
clients’ main defined identity was usually race, along with intersectional-
ity with being poor and/or gay (Freeman et al., 2017). Clients carefully
assess their social workers and determine if it is even safe to self-disclose
about what may be their most closely held beliefs and experiences and this
questioning of safety may be amplified when there are racial differences
(Trahan & Lemberger, 2014). As noted earlier, studies have found that
avoidance of discussion around race (by the therapist or social worker) is
considered participating in color blindness and clients are less likely to trust
their therapist or even continue in therapy (Hook et al., 2016). Practicing
from a culturally humble stance, that is, being curious about the client’s
culture, is associated with favorable opinions of the therapist/social worker,
even in the case of an unintentional microaggression (Davis et al., 2016).
Awareness, sensitivity, and respect usually ground these conversations.
One way to have such a conversation is to look for what Hook, Davis,
Owen, and DeBlaere (2017) call “cultural opportunities [which are] mark-
ers that occur in therapy in which the client’s cultural beliefs, values, or
other aspects of the client’s cultural identity could be explored” (p. 32).
These are natural openings that are derived from clients’ statements in the
course of the conversation and unfold naturally. Social workers need to be
attuned to cultural identity issues and decide if and how to explore them
further (Owen et al., 2016). In the video example described earlier, the
patient stated she could maybe attend an exercise class at her church. Per-
haps the physician could have replied, “It sounds like your church is very
important to you and provides supports in a lot of different ways.” This
might provide an opening for her to talk about her church, its role in her
life, and other ways it might support her through depression. Of course, not
all African Americans are involved in churches or other houses of worship,
but this client specifically brought it up.
Another way to address race or other cultural identities is to directly
ask about their role(s) in clients’ lives through the use of tools or hand-
outs, such as in the HTH1 study. A box labeled discrimination or immigra-
tion experiences could be inserted into an agenda-setting tool, described
 MI through the Lens of Critical Race Theory 197

in Chapter 4. Figure 10.1 is a cultural assessment tool I created to assist

counselors at a residential substance use program who wanted to include
culture in their assessment protocol. Based on an ecomap format, it invites
clients to identify (in the center rings) the various identities that are most
important to them. This addresses the intersectionality of multiple cultural
identities (Lee, 2010), which can include race, gender, religion, ability sta-
tus, gender identity, being a member of deaf culture, and so forth. Cli-
ents are asked to select several (or more) of the rectangular boxes to fill in
regarding how these areas relate to their identified cultures. The labels on
the boxes could be customized to fit the contexts of clients in other types of
agencies. Clients may draw lines as noted in the legend to characterize the
strength or difficulty of the topic in terms of its relationship associated with
their cultural identities. This tool has been used in social work education
classes when studying diversity and is especially helpful for White students
to think about what their culture is, which many have not ever considered.
After it is completed, clients (or students) are asked to debrief the tool, lead-
ing to some rich discussions. For clients, the discussion could also examine
how the identified areas impact their presenting problem/target behavior.
MI practitioners utilize the spirit of MI along with open-ended questions,
as well as many complex reflections throughout the discussion. OARS skills
are a way to implement cultural humility and cultural discussions.

Discussing Racial Differences

A third way to voice the counternarrative is to discuss our own relation-
ship with the client. This is one of the most difficult conversations and
probably would not be something to address in the first or second meeting
with clients, unless they initiate it. Clients who are people of color and
work with a social worker of a different race may be initially cautious.
However, studies of cross-racial counseling have found that when counsel-
ors are willing to broach the issue of race, clients are more likely to report
a strong working alliance. Those who avoid bringing up race tend to be
seen as less credible (Zhang & Burkhard, 2008). The authors of one study
speculated that counselors who do bring up race (in a culturally humble
manner) may help reduce anxiety in clients who are unsure as to what to
expect. When the clients were White and the counselors were people of
color, discussions of race had no bearing on how clients rated their coun-
selors (Zhang & Burkhard, 2008). The study does not mention how race
was broached in the counseling settings, and no mention was made of any
sort of assessment tool, so it is assumed it was done by just bringing it up.
How might this be done, using MI? Let’s go back to the video example.
Perhaps the physician, after talking to the patient for a while, might say
something like, “I’m wondering if it would be ok to go off track a little
198
FIGURE 10.1. Cultural assessment.

Copyright © 2006 Melinda Hohman. Reprinted with permission in Motivational Interviewing in Social Work Practice, Second Edition, by Melinda
Hohman (The Guilford Press, 2021). Permission to photocopy this figure is granted to purchasers of this book for personal use or use with clients
(see copyright page for details). Purchasers can download enlarged versions of this figure (see the box at the end of the table of contents).
 MI through the Lens of Critical Race Theory 199

bit here?” The patient affirms, yes. He could say to her, “I’m wondering
if you would be willing to share with me what culture you identify with?”
and “I have some knowledge about some ways to address depression. But
first, I am curious as to what you think might work for you based on your
knowledge of yourself, your own culture, and what resources are available
to you.” I don’t know where she would go with the conversation, however
the physician has acknowledged that the patient is the expert on herself and
that she has resources in her community. In other settings, when appro-
priate and when a relationship has been established, social workers could
simply ask how a client feels about working with someone of a different
race, using cultural humility and a willingness to listen and learn (Hook et
al., 2016).
Sometimes clients bring up race. Lee (2010) indicates that it could be
due to previous positive experiences “with people like you” or it could be
due to their own implicit or even explicit bias, if the social worker is a
person of color. Clients who are people of color may have had previous
negative experiences with White social workers, other professionals, or
even neighbors, classmates, or coworkers. I will use the role-play state-
ment I described above as an example. I will assume that the client is Afri-
can American, the social worker is White, and that the setting is the door
knock, as it is called, in child welfare work. This is when a social worker
first goes to a home when there has been a report of suspected abuse or
neglect.
Let’s take a look at the possible context. As presented in Chapter 2,
when clients are in involuntary situations, such as child welfare, proba-
tion, or mandated treatment, reactance comes into play. Reactance theory
states that when autonomy or competence is threatened, people push back
in ways to preserve their autonomy, such as through arguing, defending,
noncompliance, disengagement, or even aggression (Mirick, 2012). This
is framed as normal behavior as a response to the threat of loss. It is even
more compounded in the child welfare system where the loss may be actual:
the possibility of the removal of one’s child or children. If not outright child
removal, then it is the presence of a system that is perceived as paternalistic
and makes demands or expectations of parental behavior. People of color
may find themselves doubly oppressed. Not only do they experience every-
day racism, but now they may feel oppressed by a system that is meant to
protect families (Rooney & Blakey, 2018). The counternarrative includes
factual information about the disproportionate involvement of African
American children (and other children of color) in the child welfare sys-
tem and foster care. Sometimes, the behavior of social workers who don’t
understand their clients’ culture, interpret behavior through a color-blind
framework, and make decisions based on biases and their own cultural
expectations (Miller, Cahn, & Orellana, 2012; Ortega & Faller, 2011).
 200 IMPLEMENTATION

MI provides a communication skill set for social workers to engage clients, elicit
their desire for change, understand their motivations, and pull from those values to
evoke changed behavior. This may sound impossible or as if it requires too much of
the social worker—when that is just the opposite. When social workers use the spirit
of MI to engage with clients, they are giving the clients the power to create their
change. Clients feel heard and know their voices are respected. They begin to hear
themselves and connect the dots between their personal values, current behaviors,
and the changes they want to have in their lives.
Culture is not only race, ethnicity, or socioeconomic status but also religion,
social belonging, trauma experiences, language, and family norms, to name a few.
It is up to the client to determine their cultural identity and it is our responsibility
to ask them about it. As a Black woman who works in the child welfare system,
MI helps me to bridge doubts, fears, false expectations, and sometimes racism, to
partner with clients.
I recently worked with a family whose son was born with a positive toxicology
for opiates. The mother and father had three older children who remained in the
Middle East with paternal grandparents. Using affirmations of her desire to be a good
mother along with reflections, the mother disclosed to me that she had no idea that
the pills her doctors kept prescribing her for her back-injury pain were considered
a drug. The mother had a language barrier and was attempting to trust Western
medicine to support her needs. Later, while in a treatment program, she told me she
prayed to Allah and was cured. She stated she did not need to or want to take any
more pills. Although I was surprised by her initial response to sobriety, I supported
her decision. She agreed to drug testing to show evidence to the court that she was
abstinent. She continued to test negative for all substances. At the following court
hearing I was able to return her son to her care upon his discharge from the hospital.
MI spirit and skills enabled me to make a connection that supported the client’s
change. By meeting the client where she was and taking the time to understand her
perspective, I was able to support her through the process, which in many ways
was frightening to her. I let her lead and made sure she had what she needed to be
successful, and in this case that meant having her son returned to her custody.

                     M arya Wright, MSW

                     Child welfare worker
                     Oakland, California

The profession has recognized this and there are many efforts underway
to address these problems. But the counternarrative lives on. (SW = social
worker; C = client; [MI skills/OARS are in brackets].)

SW: (Walks up to the front door of a house and knocks. The door
opens.) Are you Mrs. Fields? My name is Jessica Chapman and I
am from the county child welfare office.
 MI through the Lens of Critical Race Theory 201

C: Oh great, another White woman.

SW: It sounds like you have had some bad experiences with other
White social workers. [complex reflection]
C: (a harsh laugh) Yeah, you could say that alright. All you people
want to do is come into this community and take our kids.
SW: You’ve heard some things that were pretty negative about child
welfare social workers. [complex reflection]
C: Don’t you people even have any social workers who are Black?
SW: You would prefer to be talking to someone who is more like you
and really understands you. [complex reflection]
C: You have no idea what my life is like and I am sure it isn’t like yours
at all. I don’t need a White girl telling me what to do.
SW: Your own bad experiences with social workers included them
being bossy and thinking they had all the right answers for your
life. Can I ask if I may come in your house to continue our con-
versation? I know you are really busy and so this won’t take long.
[complex reflection; closed question; sharing information]
C: Yes, come in. But make it quick. (Invites the social worker inside.)
Now, what is it that you want?
SW: As I mentioned, I am from child welfare services. We need to talk
a bit about a referral that was made about your son, and I am
hoping that this is a better experience than what you’ve had in
the past. I’d be interested in hearing about the professionals who
wanted to tell you what to do and were frankly, probably racist,
or we could talk about your son, or we could do both. How would
you like to start? [sharing information; supporting autonomy;
open question]

The social worker was tasked with meeting with the parent to discuss
a referral that had been made to the child welfare agency. The parent imme-
diately noted their racial differences and implied that she had had negative
experiences with other social workers or professionals. The social worker
did not get defensive by explaining herself nor did she assert power (e.g., “I
can come back with the police if you don’t want to talk”), and instead used
complex reflections to hear the voice of the client and acknowledge that she
had heard her concerns. The social worker also honored her autonomy by
asking permission to come into her house, recognizing that the parent was
busy, and also giving her a choice as to how she would want to proceed.
Most parents would want to get to the topic at hand, which is why a child
welfare social worker was at their door, and after that discussion, the social
worker should return to the topic of racism/discrimination that the parent
202 IMPLEMENTATION

had experienced. The parent could have been dealing with a school system
administrator who made a remark about her son and unjustly suspended
him or an administrative assistant who gave her a hard time when she went
to seek mental health counseling for her son. All the more reason for the
social worker to listen to the parent’s experiences through the use of OARS
skills.

Final Thoughts

Thinking about conversations about race, racism, and discrimination may

make social workers uncomfortable, and yet these problems are infinitely
intertwined with the daily lives of your clients, your coworkers, and in the
systems that surround you. As a social worker, you are mandated to pro-
mote social justice by the Code of Ethics (NASW, 2015) and it can begin
at the interpersonal level. Clients know when you are approaching them
with the MI spirit and cultural humility and usually they are willing to
overlook any mistakes you might inadvertently make when trying to initi-
ate conversations about race or some other area of diversity (Davis et al.,
2016). Perhaps the best skill for these conversations is to just listen without
any judgment or challenge of clients’ counternarratives (Murray-Garcia,
Harrell, Garcia, Gizzi, & Simms-Mackey, 2014). CRT and cultural humil-
ity extend the use of MI beyond the micro/interpersonal level to help social
work practitioners not only address a target behavior but also acknowledge
the whole person before them, and the mezzo and macro contexts in which
they dwell (Berg, 2015; Gwadz et al., 2017).

EPAS Discussion Questions

EPAS 2: Engage Diversity and Difference in Practice

 Apply and communicate understanding of the importance of diversity
and difference in shaping life experiences in practice at the micro, mezzo,
and macro levels.
 Present themselves as learners and engage clients and constituencies as
experts of their own experiences.
 Apply self-awareness and self-regulation to manage the influence of personal
biases and values in working with diverse clients and constituencies.

1. Select one of the vignettes from the other chapters. What might be
some ways that you could bring up diversity and difference with
 MI through the Lens of Critical Race Theory 203

the presented client? What would you say? What type of MI skill
did you select?
2. Look for a cultural opportunity with a current client and, using
OARS skills, find out more about one of their important cultural
identities. What did you learn from their counternarrative?
3. Select one of the online implicit bias/association tests (https://
implicit.harvard.edu/implicit) and take it. What did you learn
about yourself? How might you address any bias (which we all
have)?
 C hapte r 11

Innovative Applications of
Motivational Interviewing

EPAS 3: Advance Human Rights and Social, Economic, and

Environmental Justice
 Engage in practices that advance social, economic, and
environmental justice.
EPAS 8: Intervene with Individuals, Families, Groups, Organizations,
and Communities
 Apply knowledge of human behavior and the social environment,
person-in-environment, and other multidisciplinary frameworks
in interventions with clients and constituencies. (CSWE, 2015,
pp. 7, 9)

Are You Up for the Challenge?

Like many other social workers, you may have gone into the profession
to help relieve human suffering. You may be interested in direct practice,
family work, community organizing, or policy practice, but the ultimate
goal is often the same: to make a difference. MI is a micro practice method,
and those who are reading this book are most likely in direct social work
with individuals and families. However, MI, as noted in Chapter 1, sits in
a context of the severe social problems that many clients must deal with on
a daily basis. How does MI fit into the larger macro world of social justice

204
 Innovative Applications of MI 205

and how we confront human suffering? One way to examine it is through

the Grand Challenges of Social Work (GCSW).
The GCSW are 12 broad and ambitious goals that aim at interven-
ing in some of America’s most pressing social problems (Grand Challenges
Executive Committee, 2013). The GCSW were introduced in 2016 and are
led by the honor society, the American Academy of Social Work and Social
Welfare (Uehara, Barth, Coffey, Padilla, & McClain, 2017). The purpose
of the GCSW is to move the social work field forward in terms of bold
research, policies, practices, and educational preparation (Williams, 2016).
Similar to grand challenges written by the National Academy of Engineer-
ing, the National Institute of Mental Health, and the Bill and Melinda
Gates Foundation, among others, the GCSW were written by leaders and
faculty from schools of social work, representatives from social work orga-
nizations, practitioners, and students. GCSW provides “a social agenda for
America” (Lubben et al., 2018, p. 1) from a social work perspective. Col-
laborations and community-research partnerships for each challenge have
been established to bring to scale social work interventions that are sustain-
able and impactful (Barth, Fong, Lubben, & Butts, 2018). Each of the 12
GCSW is included in Table 11.1. See https://grandchallengesforsocialwork.
org for more information about the GCSW.
Table 11.1 also lists a selection of research studies of MI that fall under
the various challenges. Social work researchers are noted, and these studies
represent other researchers as well, from fields such as medicine, counsel-
ing, nursing, public health, and psychology. Their studies are important
to include, for social workers almost always work interprofessionally and
reaching these lofty goals cannot be achieved alone (Gehlert, Hall, & Pal-
inkas, 2017). The table also shows the breadth of current MI research,
although it is not fully represented as it is so extensive in some of the areas.
It also shows the variation in research methods. Some of the studies are
randomized controlled trials or systematic reviews of MI as an interven-
tion or MI as one part of the intervention, or are conceptual descriptions
of how MI is applied to a certain behavioral area, such as treating complex
trauma, or in intimate partner violence work. Most of these studies are
micro or mezzo interventions, which has been a critique of MI as noted in
Chapter 1. A concern is that this focus may reinforce the belief that these
social problems are self-caused and need individual solutions while leaving
out the larger macro aspects (Lauri, 2019). I believe social workers can
do both: work as micro/direct practitioners while understanding the larger
context of where the work fits in with the bold goals. The Heart to Heart
study (Gwadz et al., 2015) discussed in Chapter 10 is an example of the use
of MI, among other components, that helped participants who were HIV
positive to move forward to access medical care. This would be one step
toward “closing the health gap” of health disparities (#2 on the GCSW list).
206 IMPLEMENTATION

TABLE 11.1. The Grand Challenges for Social Work and Some Related MI
Research/Practice
1. Ensure healthy development for all youth.
• MI to engage parents in a program for elementary-aged children (Frey et
al., 2019)*
• MI in childhood obesity treatment (Borrello, Pietrabissa, Ceccarini,
Manzoni, & Castelnuovo, 2015)
• Brief interventions for cannabis use in emerging adults (Halladay et al.,
2019)
• MI to reduce secondhand smoke exposure in Head Start children (Eakin et
al., 2014)
• MI to improve middle school academic performance (Strait et al., 2012)
• MI in parental communication for safe teen driving (Hamann et al., 2019)
• Brief MI for teen violence and alcohol use (Cunningham et al., 2012)
• MI to support families exposed to adverse childhood experiences
(Eismann, Brinkmann, Theurerling, & Shapiro, 2019)
• MI to increase breast feeding (Franco-Antonio, Calderón-García,
Santano-Mogena, Rico-Martín, & Cordovilla-Guardiar, 2019)

2. Close the health gap.

• MI to increase physical activity in people with chronic health conditions
(O’Halloran et al., 2014)
• MI for parent–child health interventions (Borrelli, Tooley, &
Scott-Sheldon, 2015)
• MI for medication adherence (Salvo & Cannon-Breland, 2015)
• MI and self-affirmation for African Americans with hypertension
(Boutin-Foster et al., 2013)
• MI and other interventions to increase HIV care and medication use
(Gwadz et al., 2015)*
• MI to increase health screening (Miller, Foran-Tukker, Lederberger, &
Jandorf, 2017)
• MI for treatment engagement of low-income mothers with depression
(Sampson, Zayas, & Seifert, 2013)*

3. Stop family violence.

• MI intervention of personal goal setting for women who had experienced
IPV (Saftlas et al., 2014)
• MI intervention for depression in IPV survivors (Wahab et al., 2014)*
• Brief MI intervention for partner-abusive men (Crane & Eckhardt, 2013)
• MI-based IPV perpetrator intervention for incarcerated men (Connors,
Mills, & Gray, 2012)
• Outreach and services for survivors of human trafficking (Wirsing, 2012)
• MI and trauma-informed work with IPV survivors (MI and IPV
Workgroup, 2010)*
• MI in an elder-abuse prevention program (Mariam et al., 2015)

4. Advance long and productive lives.

• Motivational strategies to prevent frailty in older adults with diabetes
(Vaccaro, Gailard, Huffman, & Vierira, 2019)
• MI to encourage hearing aid use (Aazh, 2016)
                           (continued)
 Innovative Applications of MI 207

TABLE 11.1. (continued)

• MI as a treatment for complex trauma in adults (Lawson et al., 2013)
• MI to engage older adults in fall prevention (Kiyoshi-Teo et al., 2019)
• MI for older adult health behaviors (Purath, Keck, & Fitzgerald, 2014)
• MI to help promote farmers market use among people with low income
(Freedman et al., 2019)*
• MI in a food pantry to increase food security (Martin et al., 2013)

5. Eradicate social isolation.

• MI for perceived loneliness and prostate cancer screening (Cadet, Burke,
Mitchel, Conner, & Nedjat-Haiem, 2019)*
• MI to re-engage those with severe mental illness in work, study, or
community (Hampson, Hicks, & Watt, 2015)
• MI to support the coming out process (McGeough, 2020)*

6. End homelessness.
• Engaging people who are homeless with co-occurring disorders (Sun,
2012)*
• Group MI for adolescents who are homeless (D’Amico et al., 2015)
• Group MI to engage veterans who are homeless in treatment (Santa Ana,
LaRowe, Armeson, Lamb, & Hartwell, 2016)
• Brief MI to engage veterans who are homeless in primary care (O’Toole,
Johnson, Borgia, & Rose, 2015)
• MI implementation in permanent supportive housing (van den Berk-Clark,
Patterson Silver Wolf, & Ramsey, 2015)*

7. Create social responses to a changing environment.

• MI intervention to reduce energy consumption (Klonek & Kauffeld, 2015)
• MI to engage in conversations about environmental behavior (Klonek et
al., 2015)
• MI to increase energy saving in organizations (Endrejat et al., 2017)
• MI for community-engaged scenario planning regarding sustainability
(Costanza et al., 2017)
• MI use by environmental inspectors (Forsberg, Wickström, & Källmén,
2014)
• MI for increasing sustainable laundry behavior (Conrady, Kruschwitz, &
Stamminger, 2014)

8. Harness technology for social good.

• Computer-assisted MI social network analysis for housing first residents
(Osilla, Kennedy, Hunter, & Maksabedian, 2016)
• Technology-delivered adaptations of MI for health behaviors (Shingleton
& Palfai, 2016)
• Telemedicine-based alcohol services for rural clients on probation (Staton-
Tindall et al., 2012)*
• Multicultural web-based MI for clients with first-time DUI (Osilla,
D’Amico, Díaz-Fuentes, & Watkins, 2012)
• MI conversations for mental health via chatbots (Liao & He, 2020)

                           (continued)
208 IMPLEMENTATION

TABLE 11.1. (continued)

9. Promote smart decarceration.
• Recovery management MI checkups for women post incarceration (Scott
& Dennis, 2012)
• Web-based MI intervention for substance use treatment engagement for
those in the criminal justice system (Walters et al., 2014)
• Mental health and substance use treatment engagement intervention during
community reentry (Begun, Early, & Hodge, 2016)*
• Brief MI intervention for women in jail (Cigrang et al., 2020)

10. Reduce extreme economic inequality.

  —none—

11. Build financial capability for all.

• Supported employment for transitional-aged youth (Cohen, Klodnick,
Stevens, Fagan, & Spencer, 2019)*
• Financial social work and MI (Sherraden, Frey, & Birkenmaier, 2016)*

12. Achieve equal opportunity and justice.

• MI to engage students in multicultural courses (Venner & Verney, 2015)
• MI in community policing (Rollnick, 2014)
Note. IPV, intimate partner violence. Asterisks (*) denote social work researchers.

Gwadz and colleagues (2015) also recognized the larger societal issues that
play a role in the health gap. While their work did not focus on address-
ing racism, they did acknowledge its role for the participants as part of the
intervention. Perhaps their work will give further visibility to racism as a
larger issue in medicine (and society) that needs to be confronted. Through
research–practice partnerships, on-the-ground direct-practice social work-
ers can implement evidence-based practices such as MI and MI-based inter-
ventions to help in the solutions to these complex problems (Gehlert et al.,
2017). Solving these intractable problems takes all social workers to work
toward their end.
The literature review did not find any MI studies for the challenge
of “reduce extreme economic inequality,” and it was limited for “achieve
equal opportunity and justice.” MI was not meant to be a panacea (Miller
& Rollnick, 2013), but having these broad challenges could spur research-
ers and practitioners to think how MI might be used in these areas. For
instance, using MI to encourage clients to apply for earned income tax
credits would be one step (however small) toward reducing extreme eco-
nomic inequality. Of course, social workers would also want to work on, or
at least be aware of, other issues, such as advocating for policies that sup-
port livable wages, humane working conditions, work-based child care, fair
housing practices, and the like (Henly et al., 2018; Padilla & Fong, 2016).
One of the benefits of being a social worker is that most are not limited
 Innovative Applications of MI 209

to working in one area or method and all are educated to work across the
micro, mezzo, and macro systems. The rest of this chapter will focus on the
use of MI in three areas: trauma-informed care, food insecurity, and envi-
ronmental work. They were selected as the first two areas are common in
social work practice, cutting across many fields of practice and the GCSW,
and the third is relatively new to our profession and affects all of us.

Trauma-Informed Practice and MI

As has been noted earlier, MI was developed specifically for those with
problem alcohol use and was expanded to client drug misuse (Miller &
Rollnick, 2013). Interest in MI and its research, developed rapidly in the
area of health behavior change, with practitioners and researchers alike
seeing its potential for intervening in difficult and chronic health problems
such as diabetes, hypertension, obesity, and the concomitant medication
and lifestyle adherence (Lundahl et al., 2010). MI use and research also
expanded to mental health treatment and with clients in the child welfare,
adult protection, and criminal justice systems (Mariam, McClure, Robin-
son, & Yang, 2015; Stinson & Clark, 2017). What do all of these practice
areas, including those in the GCSW, have in common? Many of the clients
across these systems have high rates of trauma (SAMHSA, 2014a). This
seems pretty intuitive for areas of practice such as addictions, intimate part-
ner violence, mental health, and criminal justice, for instance. However,
research has also found a strong relationship between childhood trauma
(also known as adverse childhood experiences, which include experiencing
or witnessing violence, neglect, parental incarceration, substance misuse,
suicide, and/or mental health problems) and later chronic health problems
and decreased life expectancy (Centers for Disease Control and Prevention
[CDC], 2013). Awareness and understanding of trauma is important for
social work practitioners and researchers, no matter their area of focus.
What is trauma? SAMHSA (2012) defines it as “trauma results from
an event, series of events, or set of circumstances that is experienced by
an individual as physically or emotionally harmful or threatening and that
has lasting adverse effects on the individual’s functioning and physical,
social, emotional, or spiritual well-being” (p. 2). Traumatic events are usu-
ally unexpected and may overwhelm a person’s ability to cope, at least in
the short run, or over a longer period of time, depending on the type of
trauma and the person’s response to it. Trauma events can include natural
disasters, accidents with physical injuries, violence, physical and/or sexual
abuse, warfare, mass shootings, starvation, or even coping with a physical
disease or diagnosis (SAMHSA, 2014a). Involvement with child welfare/
foster care/child removal, homelessness, immigration experiences, and
210 IMPLEMENTATION

racial discrimination/microaggressions may also cause trauma (Helms,

Nicolas, & Green, 2010; Hopper, Bassuk, & Olivet, 2010; Riebschleger,
Day, & Damashek, 2015; Williams, 2020). Trauma can occur on the
individual level, group levels (such as for first responders and journalists),
community levels (such as lead in water supplies), and through historical
trauma (for instance, in Holocaust survivors and their children, Native
Americans who were removed from their families through forced board-
ing school placement, and refugees from political terror) (Evans-Campbell,
2008; Nagata, Trierweiler, & Talbot, 1999; SAMHSA, 2014a). Trauma
may occur over the lifespan and accumulate, placing older adults espe-
cially at risk for mental and physical health problems (Ernst & Maschi,
2018).
How trauma impacts children and adults can depend on whether the
trauma was directly experienced or observed, isolated or a part of other
trauma experiences, intentional or accidental, and expected or unexpected.
Individual and social factors can affect or mitigate the impact of trauma as
well (SAMHSA, 2014a). Adults who have experienced trauma, especially
as children, may have difficulties with relationships and trust, or height-
ened impulsivity (Lawson, Davis, & Brandon, 2013; Leitch, 2017). Other
trauma-related symptoms may include alcohol and/or substance misuse,
depression, anxiety, self-harm, or suicide attempts (SAMHSA, 2014b). Not
everyone who has trauma symptoms may meet the criteria for posttraumatic
stress disorder (PTSD), which include flashbacks, intrusive thoughts, anger,
isolation, heightened vigilance, anxiety, nightmares, insomnia, isolation,
and irritability, among others (American Psychiatric Association, 2013).
Some have suggested that PTSD be reframed as posttraumatic stress injury,
to take the focus off of the “disorder” and put the focus on injury as some-
thing that happened to the person (Meyers & Miller, 2013). Trauma, in the
form of continuing PTSD symptoms, that is not recognized or treated can
impact treatment outcomes, especially in substance use or mental health
settings, due to problems with engagement or an increased likelihood of
premature termination (SAMHSA, 2014a; Simpson & Miller, 2002).
What does all this mean for MI practitioners, all of whom will see
trauma but not necessarily treat it? Trauma-informed care, or TIC, in con-
trast to trauma-specific treatment, is a response to the high rates of trauma
that human service and medical providers see in their clients. It is struc-
tured by the four R’s: that you Realize the extent and impact of trauma
in your clients, that you are able to Recognize trauma symptoms for what
they are (protective behaviors) and not label them as pathological, that
you Respond by using trauma-informed policies and practices in your
organization, and that you Resist retraumatizing clients, even inadver-
tently (SAMHSA, 2014b). For example, most physicians may never treat
trauma, but trauma-informed doctors may describe to patients the area of
 Innovative Applications of MI 211

their bodies that they will be touching and give the option to wear street
clothes instead of a gown (Raja, Hasnain, Hoersch, Gove-Yin, & Raja-
gopalan, 2015). Human service agencies can avoid retraumatization by
screening for trauma events and related symptoms in all clients, including
clients in individualized treatment planning and other decision making,
creating gender-specific groups in settings where group work is used, and
gathering only the necessary information during assessment. Policies and
procedures are examined and established that promote mutual respect,
listening, trust, collaboration, client empowerment, and safety (Leitch,
2017; SAMHSA, 2014a). If trauma treatment is not provided within a TIC
agency, interagency collaboration should be established to refer clients for
trauma-specific services, if clients are interested and further treatment is
indicated. TIC programs may use organizational assessment or benchmark
tools to determine implementation fidelity to the values and practices of
TIC (SAMHSA, 2014b; Yatchmenoff, Sundborg, & Davis, 2017).
MI practitioners work to create safe relationships with all clients. Like
MI and cultural humility, MI and TIC are quite complementary (MI and
Intimate Partner Violence Workgroup, 2010). Recognizing trauma and its
impacts gives another layer of depth to your work. In MI and in TIC as
well, the focus is on the client–social worker relationship, engaging, cli-
ent strengths, supporting autonomy and choice, using empathy (reflective
listening) to understand clients’ experiences and perspectives, supporting
change or no change, and providing hope (Knight, 2015; Lawson et al.,
2013; Levenson, 2017). TIC practitioners understand that clients may be
reluctant to engage and trust, even in the presence of a warm and com-
passionate relationship (Lawson et al., 2013). MI practitioners understand
reactance theory and can use TIC to connect reactance behaviors with
trauma and respond with continued empathy and OARS skills (MI and
Intimate Partner Violence Workgroup, 2010). The caution and wariness
some clients may show may mean that we need to recycle through the four
processes, returning to Engaging and Focusing as needed (Lawson et al.,
2013; Miller & Rollnick, 2013).
While there are few studies of MI and TIC, MI has been tested as a
method of engagement and prelude to cognitive-behavioral trauma treat-
ment for those with PTSD from military service or from physical accidents,
for instance (Murphy, Thompson, Murray, Rainey, & Uddo, 2009; Seal et
al., 2012; Zatzick et al., 2011). The target behaviors in these studies were
to connect client trauma with related symptoms and motivate clients to
participate in trauma treatment as part of a multistep intervention. Most
studies in this area have found MI to be effective in engaging clients in fur-
ther treatment. MI is especially appropriate in these situations as the spirit
and skills of MI support client autonomy and relationship safety. Further
research is needed of how MI and TIC, when used together (with fidelity
212 IMPLEMENTATION

to each practice), increases MI’s effectiveness. This could be especially true

in studies/programs where MI has been tested but found to make no differ-
ence. Perhaps the inclusion of trauma recognition and TIC, along with MI
use, can positively affect outcomes.

Food Insecurity and MI

Another common issue that cuts across the GCSW, is considered a trauma,
and is a major force in the social determinants of health/mental health, is
food insecurity (Chilton, Knowles, Rabinowich, & Arnold, 2014; Council
on Community Pediatrics, 2015; Gunderson, Engelhard, Crumbaugh, &
Seligman, 2017; Hecht, Biehl, Buzogany, & Neff, 2018; Shim & Comp-
ton, 2020; Sun et al., 2016). Food insecurity has been defined as when
“access to adequate food is limited by a lack of money and other resources”
(Coleman-Jensen, Rabbitt, Gregory, & Singh, 2019, p. v). In 2018, about
37 million people, or 11.1% of the U.S. population, were considered food
insecure. As shown on Table 11.2, 4.3% of the population in 2018 were
considered very low food secure, which is when normal eating patterns are
disrupted and food intake is reduced (Coleman-Jensen et al., 2019). Not
only is the food quality nutritionally poor for these groups, but quantities
are reduced.
Those most likely to be food insecure are people with low incomes,
families with children under age 6, families headed by single women or
men, children in immigrant families, and African American or Latinx fam-
ilies, those who are experiencing homelessness, and both urban and rural
Native American/Alaskan Natives (Colemen-Jensen et al., 2019; Council
on Community Pediatrics, 2015; Jernigan, Huyser, Valdes, & Simonds,
2017). The head of the household may be unemployed, underemployed,
or work several low-paying jobs. Parents struggle to supply food for their
children and often forgo their own eating, putting their own health at risk.
Parents also face choices of where to spend the money that they have, such
as on utilities, housing, or medical bills, all of which might take precedence
over food (Academy of Nutrition and Dietetics, 2017; Kaiser & Hermsen,
2015). Inflation, increases in the cost of gasoline or public transportation,
or other economic events can also wreak havoc on families’ food budgets.
Lack of access to healthy food can also be due to limited locations of stores
or having only small markets with no fresh produce available. Low-income
communities are often food deserts or areas where there are no grocery
stores (Hecht et al., 2018). As the current U.S. federal government admin-
istration is set to change rules that will remove about 700,000 people from
SNAP (Supplemental Nutrition Assistance Program), the public govern-
ment safety net program, the demand on charitable food services including
 Innovative Applications of MI 213

TABLE 11.2. Rates of Low Food Security and Very Low Food Security in the
United States, 2018
Low food Very low Total food
security food security insecurity
(%) (%) (%)
National average 6.8 4.3 11.1
All households with children 9.9 4.0 13.9
Households with children under age 6 10.5 3.8 14.3
Households headed by single women 18.4 9.4 27.8
Households headed by single men 10.6 5.3 15.9
Women living alone 7.7 6.5 14.2
Men living alone 5.9 6.6 12.5
Households with Black heads of 12.1 9.1 21.2
household
Households with Latinx heads of 11.1 5.1 16.2
household
Households located in cities 7.9 5.3 13.2
Households located in rural areas 7.9 4.8 12.7
Elderly living alone 5.5 3.4 8.9
Note. Data from Coleman-Jensen, Rabbitt, Gregory, and Singh (2019). Household Food Security
in the United States in 2018, ERR-270. USDA, Economic Research Service.

food banks and pantries and places where free meals are provided will
increase (Dickinson, 2019).
Food insecurity in children is related to malnutrition-based problems
that may include failure to thrive, being underweight or obese (due to the
consumption of nutrient-poor but calorie-dense foods, such as fast foods),
developmental problems, health issues including more frequent hospital
visits, anxiety and depression, and hyperactivity, among others (Council on
Community Pediatrics, 2015). Children see what parents are giving up for
them and worry about their parents’ health, in addition to their own coping
with food insecurity (Leung et al., 2020). Studies have found links between
adult food insecurity and depression and other mental health problems,
especially in parents who experienced adverse childhood experiences them-
selves, which are all in turn related to the development of chronic diseases,
such as diabetes and cardiovascular disease (Chilton et al., 2014; Hecht et
al., 2018; Shim & Compton, 2020; Sun et al., 2016).
The American Academy of Pediatrics (Council on Community Pediat-
rics, 2015) recommends universal screening for childhood food insecurity
and that it be done in settings where children are seen, such as primary
care, hospitals, schools, and behavioral health programs, by physicians,
214 IMPLEMENTATION

nurses, or social workers (Kaiser & Hermsen, 2015). Screening should also
be done periodically, as food insecurity can be episodic (Academy of Nutri-
tion and Dietetics, 2017). A two-item screening tool, with items derived
from a longer instrument, has been validated to detect food insecurity in
families with children. The same two items have also been validated for
adult-only households as well (Gunderson et al., 2017). The two items are
(1) “Within the past 12 months we worried whether our food would run
out before we got money to buy more,” and (2) “Within the past 12 months
the food we bought just didn’t last and we didn’t have money to buy more”
(Hager et al., 2010, p. 29). Responses are “often true,” “sometimes true,”
or “never true,” with the first two responses to either question being con-
sidered a positive screen.
Food insecurity has been called a silent plague due to the stigma,
shame, and isolation that it can cause (David, 2017). Having conversations
with parents about food security and diet practices can be uncomfortable,
as parents may worry about possible child welfare reporting for neglect if
they report difficulty in providing food to their children (Dickinson, 2019;
O’Keefe, 2016). Parents who screen positive for food insecurity should
be provided with referrals for both governmental programs and food
resources, such as food banks and feeding programs (Council on Commu-
nity Pediatrics, 2015). Some parents may feel reluctant to follow through
due to their own feelings of stigma regarding asking for assistance, worry
that others will look down on them for doing so, or concern about how
they will be treated when dealing with governmental programs (Baum-
berg, 2016).
MI, along with trauma-informed care, has been recommended as the
communication method to use when screening for food insecurity and
making referrals (Chilton et al., 2014; Stenmark et al., 2018). MI’s empha-
sis on respect, autonomy, compassion, and empathetic listening makes it
extremely compatible for parents who are struggling with shame and stigma
around the provision of food for their families, and in many instances, their
own prior trauma and concurrent mental health concerns (David, 2017).
As noted by Stenmark and colleagues (2018), the goals of the MI conver-
sations are to support parents as well as to motivate them to utilize food
resources. Physicians who frame a conversation regarding food insecurity
as a child health issue find that this helps to reduce parental hesitancy to
discuss it (O’Keefe, 2016).
The following is an example of an MI conversation of a social worker
with a parent who has screened positive for food insecurity. LaVonne, the
social worker, works at a family guidance clinic. Trisha, a 41-year-old
White woman, has come to the clinic at the suggestion of her son’s school
social worker. Her 10-year-old son, Damian, is experiencing behavioral
problems in school. Trisha herself presents as depressed and overwhelmed.
She has two other children, both daughters, who are 8 and 6. Their father
 Innovative Applications of MI 215

was incarcerated last year, receiving a long sentence for fraud, embezzle-
ment, and money laundering. He is in a prison that is about a 4-hour drive
from their home. The family visits him monthly. Trisha works several part-
time jobs, mostly in retail at minimum wage, to support her family. She
was recently laid off from one of them. Her mother also works but tries to
help with child care. Trisha answered “often true” to both food insecurity
screening questions that were included on the intake form. She is meeting
with the social worker while Damian is in a play room during their private
conversation. LaVonne is going over the information from the intake form,
gathering information for a brief biopsychosocial assessment. They have
already discussed the presenting problem (Damian’s behaviors at school)
and the family’s situation. The target behavior is addressing food insecurity
by utilizing a food pantry or other steps the client might be willing to take.
(SW = social worker; C = client; [MI skills/OARS are in brackets]; change
talk is underlined.)

SW: (Looks at intake paperwork.) Trisha, you have really had some
hard times becoming a suddenly single parent and you’re making
the best of it that you can. You’re working several jobs and yet
the money has to be stretched so far that it’s hard to cover food.
[affirmation; simple reflection]
C: Yeah, well, the little bit of savings we had ran out very quickly and
you know how high the cost of housing is around here.
SW: Rent really puts a strain on your budget. [simple reflection]
C: That, and paying for medical stuff—for my youngest daughter
with asthma—along with my car, gas, trips to the prison . . . it
all adds up. So sometimes I have to compromise on what we eat.
SW: You are faced every month with a lot of hard choices. [complex
reflection]
C: That’s an understatement, for sure!
SW: Can I ask, what do you know about resources that are available
for food? [open question; eliciting]
C: Resources? Like food stamps? I don’t know anything about them,
but I know I would never apply for them. I was raised that we have
to take care of ourselves, not rely on the government. We do ok.
When we run out of money for food, my mother will give me $20
if she can afford it. And I spend it all on the kids.
SW: Your focus is totally on their well-being. [complex reflection]
C: Yes. My kids are everything to me.
SW: I can see that. They are your priority. This is complex and hard,
as you feel strongly about being independent and also want to
216 IMPLEMENTATION

make sure your kids are well cared for. [affirmation; complex
reflection]
C: I feel really stuck. I can’t have them miss a meal or eat some junk
food just to fill them up.
SW: Would it be ok with you if I shared a little information about what
is out there regarding resources? [closed question/autonomy sup-
port by asking permission]
C: (Shrugs.) Sure.
SW: You’re right, food stamps are one resource and most likely you
would qualify for them. They really aren’t stamps anymore, but
like a debit card that you can use at stores and even some farm-
ers’ markets. You can even apply for the program right here at
our agency. It is called SNAP. I can show you where the office is,
if you want. Another resource is our local food pantry. What is
interesting about them is that they have canned food, obviously,
but have also partnered with local farmers and grocery stores to
get fresh produce that typically can’t be sold in stores because they
are small or don’t look perfect. [sharing information]
C: That’s interesting, I didn’t know about that. Let me think about
SNAP. If I were to go to the food pantry, what would I need to do?
I feel like it would be so embarrassing though. But I do like the
idea of getting fresh fruits and vegetables for my kids.
SW: You would need to take in your and your children’s identification,
like a school ID, proof of your address with a utility bill, and
some proof of your income. You would meet privately with a staff
member who would walk you through the process. You also get
to select the kinds of food you want or need. Sometimes, too, they
have cooking or nutrition classes, which some of my clients have
enjoyed. [sharing information]
C: Well, maybe I will check out the food pantry. I can just show up,
right? Or do I need an appointment?
SW: You can just show up or if you get an appointment, you don’t have
to wait in line. [sharing information]
C: Let me think about the SNAP. This is just also so hard and embar-
rassing. I never thought I would ever be in this position. We had
hard times when I was a kid when my dad left, and food was
stretched thin then, but I never thought this would happen to me
again, as an adult.
SW: Yes, you’ve been through a lot. You’re here though and wanting to
do what is best for your family. You are a fighter. [affirmation]
C: Yes, that’s me.
 Innovative Applications of MI 217

As in other MI interviews, the social worker used reflective listening,

open questions, and affirmations with sensitivity to the situation that the
client found herself facing. She made a double-sided reflection (indepen-
dence, taking care of her children, and asking for help) to show empathy for
the value conflict that the client was experiencing. She also used the E-P-E
method by asking what the client already knew about food programs, pro-
viding information about how they worked, and then discussing the client’s
thoughts on these options. She did not argue or push the client in any direc-
tion and instead, affirmed her commitment to her children’s well-being.
Having the exact details of how the food programs worked, and being able
to relay them to the client, was helpful in decreasing the client’s anxiety
about them, and possibly motivating the client to at least pursue the food
pantry. Social workers can support clients’ autonomy and dignity by refer-
ring to food banks that allow clients to choose the products that they want
and that work with clients in a trauma-informed manner (David, 2017).
MI has been used in other aspects of the food system/hunger relief. For
instance, Freedman and colleagues (2019) trained community members
(called ambassadors) in MI for peer-to-peer discussions (one-to-one and
at community events) regarding the use of SNAP benefits at local farmers’
markets. The overall goal was to increase fresh fruit and vegetable intake
in SNAP recipients’ diets. Those who engaged in the MI discussion received
coupons to use at the markets. In the study, SNAP benefit use increased at
intervention farmers’ market sites as compared to the comparison group
markets. Another study evaluated the Freshplace food pantry in Hartford,
Connecticut, which provides food as well as a type of case management
program to help participants work toward becoming more food secure.
Case management is provided by project managers who are trained in MI.
Goals may be set around employment, housing, or mental health needs,
along with appropriate referrals. The evaluation found that participants, at
one year, were less likely to be in very low food security, had increased self-
sufficiency (which was measured by a self-efficacy regarding food security
scale), and increased fruit and vegetable intake (Martin, Colantonio, Picho,
& Boyle, 2016; Martin et al., 2013). The box on page 219 is a descrip-
tion of how MI is used to work with communities regarding reducing food
waste. Another study screened older adult recipients for depression, in the
context of home-delivered meals, and used MI to engage them in mental
health treatment (Sirey et al., 2013).
The potential for MI and social work practice across the food system
is great, implementing motivating conversations regarding urban farming,
community gardens, food donation, and food recovery and repurposing,
and within farmers’ markets and feeding programs (Augustin, Sanguansri,
Fox, Cobiac, & Cole, 2020). Social workers can increase screening and
referral for food insecurity in settings that serve families, children, and
older adults. Always, food insecurity and food provision needs to be under-
218 IMPLEMENTATION

stood as occurring in the macro context of poverty, low-paying jobs, lack of

health insurance, community violence, discrimination, and the high costs
of housing (Chilton et al., 2014; Shim & Compton, 2020), all of which
need social work attention.

Environmental Work and MI

One of the biggest drivers of food insecurity, besides poverty, is climate

change and other environmental problems, which have a disproportionate
impact on those in low-income and racial communities (Grineski et al.,
2012; Kaiser, Himmelheber, Miller, & Hayward, 2015; Philip & Reisch,
2015). Social work has been slow to embrace environmental justice work
as part of its mission, although the CSWE (2015) EPAS added “EPAS 3:
Advance Human Rights and Social, Economic, and Environmental Jus-
tice,” and, as shown in Table 11.1, “create social responses to a changing
environment” is included in the GCSW (Bhuyan, Wahab, & Park, 2019;
CSWE, 2015; Dominelli, 2012; Kemp, Palinkas, & Reyes Mason, 2018;
Philip & Reisch, 2015). The NASW as well as the International Federa-
tion of Social Workers (IFSW) also call on social workers to have knowl-
edge about climate change and its impacts on clients and communities, to
consider the natural environment in the person-in-environment perspec-
tive, to help clients adapt and cope with climate change problems/disasters,
and to advocate for policy change (IFSW, 2012; NASW, 2018). Recently
social work scholars have called on the profession to go beyond a focus on
responding to the effects of climate change and degradation to that of pro-
active prevention work (Teixeira, Mathias, & Krings, 2019).
Environmental social work has been defined as being “focused on help-
ing humanity create and maintain a biodiverse planetary ecosystem which
includes humans” (Ramsey & Boddy, 2017, p. 82). Environmental social
work, or green social work, may involve responding to large issues such
as climate change, energy consumption, overfishing, water pollution, food
waste reduction (as noted in the box on page 219), and natural disasters,
as well as practicing macro interventions for environmental justice (Domi-
nelli, 2012; Ramsey & Boddy, 2017). The policy brief for the GCSW on the
environment suggests that social work researchers and practitioners address
disaster-risk reduction, populations/refugees who are displaced by environ-
mental causes, and communities’ strategies to confront environmental and
social disparities (Kemp et al., 2018). This last emphasis relates to environ-
mental justice.
Environmental justice/injustice focuses on the disproportional impact
that environmental problems have on vulnerable populations. It encom-
passes several aspects, one of which is the unfair distribution of environ-
 Innovative Applications of MI 219

MI is commonly understood as an intervention strategy used in direct-service

social work. There is extensive literature supporting the efficacy of MI in
clinical practice, and MI is most often introduced in social work curriculum
within a direct-practice context. Perhaps less recognized is the role that
MI can play in macro social work interventions. As a macro social worker
implementing a county-wide consumer education campaign around food waste
reduction, MI is a strategy I have utilized to address ambivalence to change
within communities. Although I am not working one-on-one with individual
clients to elicit behavior change, resistance to change on the issue of food
waste is something I often encounter in my community work. Although 40%
of food is wasted in the United States, with households responsible for 43%
of that waste (Natural Resources Defense Council, 2017), the phrase “But I
don’t waste any food!” is something I often hear. Utilizing an MI framework
to contextualize this, there can be feelings of guilt or shame associated with
wasting food. Wasting food is associated with wasting the resources—like land,
water, and energy—that went into producing that food. Furthermore, it can be
especially jarring to consider the reality of food waste in relation to the reality
of food insecurity in our community. To identify as someone who wastes food
at the same time that individuals and families are struggling to access healthy
and culturally appropriate food can create a cognitive dissonance that can be
difficult to overcome.
To address this ambivalence to change, I utilize a macro perspective
to contextualize food waste as social, economic, and environmental issues,
rather than the product of individual failure or negligence. I use language to
introduce the issue in a neutral, nonjudgmental way, and engage communities
in collaborative conversations about food waste. This allows me to gain their
perspectives, assess their strengths, and develop a culturally relevant strategy
for utilizing those strengths as motivators for change. I leverage the power of
collective impact and demonstrate how small changes in meal planning, grocery
shopping, food storage, and cooking habits can lead to huge positive impacts in
reducing wasted food, which goes on to benefit the economy, the environment,
and those most in need.

                        Sarah F eteih, MSW

                        Outreach coordinator
                        San Diego, California

mental burdens. For instance, the Environmental Health Coalition (EHC,

2012), a large environmental justice nonprofit in San Diego, California,
reports that one local wealthy community (comprised of 14% people of
color, 3% in poverty), has 1,500 tons of toxic substances. A somewhat
nearby low-income community (comprised of 97% people of color, 35%
220 IMPLEMENTATION

in poverty) has almost 6,500 tons of toxic substances. Other aspects of

environmental injustice include unequal protection from environmental
hazards in policy making or enforcement, and political processes that deny
local citizen participation in decision making (Philip & Reisch, 2015).
Environmental justice work tends to focus on specific communities with
the goal of empowering community members who are directly affected by
pollution, lead poisoning, mining runoff, pesticides and other poisonous
fumes/products, garbage dumping and spillage, transportation inequity,
and the like, to address the practices and policies that allow them. Philip
and Reisch (2015, p. 473) write that “environmental justice centers the
experiences of populations who are most affected by environmental deg-
radation and enhances their ability to participate meaningfully in local
environmental decision-making.” This is accomplished through commu-
nity organizing, advocacy work, and local leadership development (EHC,
2012).
What does all this mean for MI practitioners who tend to work
with individuals, families, and groups and are interested in environ-
mental communication? Some of the recent MI publications reported in
Table 11.1 for GCSW 7, “create social responses to a changing environ-
ment,” give a clue. The studies have all addressed environmental work (as
opposed to environmental justice) regarding how they used MI to com-
municate to others about target behaviors to reduce the carbon footprint
around energy usage (Endrejat, Baumgarten, & Kauffeld, 2017; Klonek
& Kauffeld, 2015), laundry washing/water usage (Conrady et al., 2014),
and environmental inspections/communication in the workplace (Forsberg
et al., 2014). Most of these studies were conducted with employees or con-
sumers. Why MI? As noted throughout this book, providing information—
or fear—to people isn’t enough to cause behavior change. Those who work
in the field of climate communication have found this to be the case: hear-
ing about climate science does not change behavior (Klonek et al., 2015;
O’Neill & Nicholson-Cole, 2009). In fact, as known from reactance the-
ory, people become more entrenched in their positions and less open to
hearing about the need for behavior change when they are told that they
need to change. Conversations about climate change can be emotionally
charged as well. Climate communicators, who are well aware of the state
of climate science, in their urgency may use confrontation to try to change
others. This may not be that much different from the urgency some social
workers experience when working in child protection or probation, for
instance, when they want to keep their clients from losing their children
or reoffending. It is easy to fall victim to the righting reflex when much
is at stake.
The studies listed above focused on the use of MI to develop the
employees’ own motivations for change and designate what behaviors
 Innovative Applications of MI 221

they might consider regarding the target behavior. Endrejat and colleagues
(2017) describe how, in group work with employees regarding increasing
energy-saving behaviors, they utilized the four processes to engage group
members, focus on which aspects, if any, of energy savings were important,
evoke regarding the benefits (personally) of energy saving regarding specific
behaviors, and plan on how to accomplish what employees designated as
important to them.
Schutt and Mah (2017), who are employed by an environmental pro-
gram called Enviromentum, engage in Climate Conversations with high
school students in Toronto, Canada. No climate science is presented;
students are given a version of a change ruler (see Chapter 5) regarding
their readiness to take action about climate change as a pre- and post-
test. Their conversations involve the use of open-ended questions to ask
students about their own concerns regarding climate change and how they
perceive their peers’ concerns (Engaging). Normative feedback is provided
regarding their peers’ actual concerns, as students tend to underestimate
them, thinking they are more concerned than their peers. This gives a basis
for further discussion on topics that will be covered (Focusing). Reflective
listening is also used throughout the class discussions, along with a heavy
emphasis on autonomy support. A somewhat traditional values card sort
is used (see Chapter 5), along with a scale that asks students to list their
top five climate change concerns. A study of 190 students who participated
found that the most common values were family (86%), health (74%), and
success (50%). The most common environmental concerns were water
and air pollution (72%) and reduced availability of food and water (69%)
(Schutt & Mah, 2017). Discussion then ensues regarding how their top
concerns fit with their important values (Evoking). Teens are then broken
into teams to discuss one of the five mitigation behavioral areas: clothing,
food, waste, transportation, and encouraging others regarding environ-
mental actions. Students are given a continuum with example behaviors
that are appropriate to adolescents. A goal of this exercise as well is to
emphasize that environmental mitigation is not an either/or but a spec-
trum of behaviors. Students are then asked to individually name one cli-
mate mitigation behavior that they might take (Planning). Enviromentum
recently created Climate Conversations 2, for use with adults, and also
refined the adolescent curriculum (Schutt & Mah, 2017). The organization
is also providing equitable access to training in MI skills as they apply to
environmental justice.
To date, no studies that use MI in the work of environmental justice have
been published, although there is some recent work on MI and leadership/
administration in general (Marshall & Nielsen, 2020; Wilcox et al., 2017). As
noted above, environmental justice mostly involves community organizing,
leadership and advocacy training of local leaders, and other advocacy
222 IMPLEMENTATION

work (Teixeira et al., 2019), and any work that discusses MI in these
contexts is limited. Costanza and colleagues (2017, p. 47) have proposed
MI use in what they call “community engaged scenario planning” for
climate change and other concerns. This involves bringing together com-
munity members in various settings to discuss their visions for their
future and how they would like to get there by using MI processes, skills,
and spirit to create a shared vision and move forward into action. This
application of MI in communities could be used in environmental justice
community organizing, or what Austin, Anthony, Knee, and Mathias
(2016, p. 272) call “micro-informed macro practice,” in that it is impor-
tant to engage community members, focus on a shared goal, evoke rea-
sons as well as methods to address the issues, and determine next steps.
Of course, social worker practitioners in this area would utilize many
macro skills as well.
The use of MI for environmental work, or any type of community
organizing, is still new and is obviously pushing the boundary of what MI
was developed for: to help individuals discover their own intrinsic reasons
for change, usually regarding some sort of health need. MI practitioners,
no matter the discipline, are careful to stay close to the model of MI as well
as follow the different professions’ ethical codes. It is important to demon-
strate the spirit of MI: autonomy support, empathy for understanding the
client’s perspective, acceptance, and a willingness to act in a collaborative
manner. The Climate Conversations approach, where values and choices
are discussed, with a general target behavior of some sort of new step or
action that is not predetermined, is an excellent example of environmental
work in keeping with the spirit of MI.

Final Thoughts

This chapter provided an overview of some of the innovative uses of MI

within the framework of the GCSW, a roadmap for addressing society’s
most intractable problems. Trauma is a concern that cuts across most of
the GCSW, impacting individuals and their families and communities. It
affects social work practice and is now the focus of social work research.
Food insecurity is a growing and often silent problem laced with stigma
and shame, and its effects, again, are seen in several of the GCSW areas or
it often exists concurrently with them. Climate change and environmental
injustices are a third cross-cutting area. While changes in societal policies
and practices are urgent, the use of MI conversations on the micro and
mezzo levels can create safe places to move social workers forward in how
to meet these challenges.
 Innovative Applications of MI 223

EPAS Discussion Questions

EPAS 3: Advance Human Rights and Social, Economic, and Environmental

Justice
 Engage in practices that advance social, economic, and environmental
justice.

EPAS 8: Intervene with Individuals, Families, Groups, Organizations, and

Communities
 Apply knowledge of human behavior and the social environment, person-
in-environment, and other multidisciplinary frameworks in interventions
with clients and constituencies.

1. How are your clients affected by environmental injustice?

2. How might MI be used to discuss clients’ concerns about
environmental injustice?
3. How might screening for trauma and food insecurity be integrated
into your work or internship site?
4. How would the use of MI facilitate screening and referral for
trauma and/or food insecurity?
 C hapte r 12

Teaching and Training

Motivational Interviewing

As noted in the first chapter, I inserted about 2–4 weeks of MI content and
skill building in an undergraduate social work practice class and a graduate
addictions course that I was teaching, around 1998. Later, based on the
work of some MINT colleagues at other universities who graciously shared
their syllabi, I proposed a full semester MI class for both undergraduate
and graduate social work students, which was approved by my school’s cur-
riculum committee, and began teaching it in 2010. My colleague, faculty
member, MINT trainer, and social worker, Richard Bradway and I estimate
that we have taught about 200 students a year, so that is, at the minimum,
over 2,000 students who have been exposed to MI since the full semester
course was initiated. Perhaps about another 800 students received instruc-
tion on MI before that time. Of course, it is up to students as interns and
professionals to determine if and how they will use MI. Many have found
that their internships and employers encourage (and now some require) the
use of MI, and they feel supported. Other schools of social work offer MI
content and courses in their curriculum. There are MINT trainers as well
on the faculties of medical schools and schools of public health, counseling
psychology, nursing, pharmacy, and other health professions. Chapter 1
lists the various studies that social work researchers have published either
on MI or on MI as part of an intervention. MI has certainly been diffused
throughout social work and other helping professions.

224
 Teaching and Training MI 225

Students, often working in the field after graduation, contact me

with questions regarding how to become a MINT member or how to put
together an MI workshop for their agency. The content of this book as well
as that from Miller and Rollnick (2013) can provide the basis for what to
teach. How MI is taught, however, is something that has been a journey for
me and does take time to learn.
One of the most valuable decisions I made in my career was to attend
the MINT Training for Trainers. This workshop is not about MI per se,
but focuses on increasing skills to be a good MI trainer. It provides train-
ees with methods and practice on how to structure exercises for learning
MI skills, from setup to implementation to debriefing trainees, all done
with the spirit of MI. MINT also provides a supportive community for
ongoing learning and sharing of ideas. More information on MINT can be
found at https://motivationalinterviewing.org/motivational-interviewing-
training. One does not need to be a member of MINT to train others in MI.
The same link provides information on how to access the MINT Trainer’s
manual.
The following are some tips, based on my experience, for those who
want to train others in MI or teach it in a university classroom. Of course,
one must be knowledgeable about MI, be able to demonstrate an MI inter-
view, and utilize MI skills throughout training. A trainer should be com-
fortable and relaxed in front of an audience and be organized about what
they want to cover and have specific learning goals for each particular
session. That said, flexibility is important, too, as is knowing when and
how to shift directions if need be. Teaching/presentation modes—such as
lecture, discussion, skill practice, and debriefing—should vary during the
training.
Another important aspect is to know the audience in advance. If you
are training in a professional work-based setting, first meet with the admin-
istrator or training coordinator regarding who will be in the audience and
whether they will be there voluntarily. Similar to working with clients and
using the four processes, trainers may need to spend more time in engag-
ing trainees if they have been forced to attend the workshop or have had
little exposure to MI. Also, what is the goal of the training as defined by
the administrator? As I covered in Chapter 9, skill change does not come
from a short or even 1- or 2-day workshop. It is ethical to let administra-
tors know what is needed to really create skill change (training plus direct
observation, feedback, and coaching over time) and what to expect from a
brief training (basically, some knowledge gain only). Knowing one’s audi-
ence is also helpful in developing examples, case vignettes, role plays, and
so forth with content specific to their work. An example of this could be a
focus on issues of adolescent foster youth, if the training workshop is for
social workers who work with this population.
226 IMPLEMENTATION

Sometimes students or trainees are surprised by the MI teaching style,

which is very interactive. Social work and other students may have a lot of
anxiety and worry about how well they will do in school. To manage their
anxiety, some expect faculty to provide information in the form of Power-
Points and lectures. Like clients who become passive in assessment-driven
services, students are passive learners in these methods: just tell me what
I need to know. In turn, their main focus is to regurgitate what they have
learned either on exams or in papers. This does not provide the best learn-
ing environment for MI. Professional social worker trainees and others can
be passive as well, perhaps just putting in their time to get through a man-
dated workshop. It is helpful to start with an exercise that gets everyone
involved and sets the tone for the rest of the course. While everyone’s style
is different, I tend to use the room by walking around, making eye contact
with everyone, and coming closer to whoever is speaking, if possible.
College students struggle with multiple demands, even more so than
a generation ago. These demands include family caregiving, child care,
outside employment, and financial burdens that include unstable housing
and food insecurity (Crutchfield, Carpena, McCloyn, & Maguire, 2020).
Sometimes doing well on exams is connected to financial aid, increasing
performance anxiety even more. All of these things can be a distraction to
learning, particularly when a baby sitter texts during the middle of class.
Professionals who attend work-based trainings also have many ongoing job
demands and may frequently check emails. I once had about five probation
officers jump up and give their apologies that they had to leave due to a
shooting in the community.
No matter the course content (MI or social work policy, for instance),
it’s important to recognize that teachers and students are partners in the
learning process and that students and professionals bring a lifetime of
experiential knowledge to the classroom. One way to manage their anxiety
is to create a relaxed atmosphere by using humor and to find chances to give
affirmations whenever possible. Evoke from students their knowledge or
experience as to how it fits with the content, recognizing their competence.
While it may be impossible to get to know all of the trainees or students,
it helps to learn some names and take time to do informal chatting. Prob-
lems may be disclosed that affect attendance or are causing distractions
and hopefully can be discussed privately with referral to supports on cam-
pus, if they are students. I have found that just as a social worker closely
watches and listens to a client in an MI conversation, it is also important to
pay attention to the audience in either the classroom or the training room.
Watch for signs of disengagement, which can be a signal to vary the teach-
ing style or that it may be time to go into an exercise. It’s also important to
work to include and recognize all of the voices in the room.
Figure 12.1 presents a model of MI teaching methods that I use over
 Teaching and Training MI 227

Engage:
Greeting and small talk
Review of previous class/session
Focus:
Topic for the class/session
Evoke:
Elicit:
Knowledge Engagement
Ideas Self-efficacy
Thoughts Learning
Methods/behaviors Motivation
Values/goals
Strengths
Provide:
Reflections
Summaries
Information (hear)
Demonstration (see)
Opportunities for practice (do)
Feedback with permission
Ideas with permission
Elicit:
Reactions
Application questions
Plan:
Next steps
Feedback from trainees/students

FIGURE 12.1. A model for training or teaching MI.

the course of one class session or community training day. It provides a

framework for my students, trainees, and me, of the methods I use. While
it is beyond the scope of this book to examine various adult learning theo-
ries, I am sharing a framework that seems to work for me. It is based on the
four processes as well as the elicit–provide–elicit (E-P-E) method of sharing
information.
Engaging students or trainees is important and can vary, depending
on the setting and context. Having ongoing relationships with students
usually means that Engaging at the beginning of the class can be a bit
shorter: perhaps mention something in the news, tell an interesting story,
or use some sort of humor. I often go to class a little early and sit next
to a student just to chat a bit. This can also be helpful in a community-
228 IMPLEMENTATION

Adjusting to life as a civilian, preparing to enter the workforce, and

reestablishing a role in the primary family unit are just a few of the
challenges that many of our veterans face. These challenges, coupled
with mental and physical illnesses, make for an extremely challenging yet
rewarding career for social workers who work with the men and women who
have served our country. As veterans navigate services at the Veterans Health
Administration, I have come to understand that many of them may avoid
having that discussion of how these illnesses are impacting their everyday
lives and the topic of mental health is not always an easy one to discuss.
My role as an outpatient mental health social worker has provided me
with the opportunity to work with veterans at many different stages of the
treatment process. Helping to engage them in treatment or expand their
interests in other treatment options encourages me to continue working on
my skills in MI. MI is an integral part of the process in how I work with
veterans in trying to understand where they are, meeting them there, and
finding out where they want to go. Through trauma-informed care, MI is
used to hone in on each individual veteran and collaboratively develop a
treatment plan that meets their needs. This may include psychotherapy.
Once engaged in psychotherapy, MI plays an integral role in trying to
keep them there. My time here at the VA has shed light on a very important
factor in the treatment process, which is that the attrition rate is very high
among our veterans. And while there are many factors that may contribute
to this, using MI skills, I do the best I can to tease out which factors may
be contributing to their ambivalence, reorient them to the goals they
established, and support their sense of self-worth and self-determination.
Coupled with other treatment modalities such as dialectical behavior
therapy and cognitive-behavioral therapy, MI has given me much more
fluidity in my interactions with veterans. I use MI as a conversational
approach to understanding the source of their avoidance of continuing
to engage in treatment or addressing the other factors limiting their
involvement in treatment, and together we work to discover a path to
building a can-do attitude that helps veterans identify reasons for change
through personal motivation.

              C hristopher Walker, MSW, ASW

              Outpatient mental health social worker
              San Diego, California

based training where the trainer might only be meeting the trainees for
the first time and only be there for a day or two. In this setting, Engag-
ing might take longer, with introductions around the room. Next, asking
about their work context, their clients, what is known about MI, and how
 Teaching and Training MI 229

it might fit in the work with their clients are ways for the trainer to find
out what knowledge they are working with and their feelings about being
in a workshop. Use of reflective listening skills throughout models will be
taught.
Focusing usually means to review what is on the syllabus for that day’s
class or what will be covered, if in a community-based workshop. Trainers
may find that their trainees know more about MI (or less) than what was
expected and planned for, and may need to adjust the content to fit attend-
ees’ learning needs, which can be negotiated with them. As for students,
they appreciate flexibility but also seem to want the structure and organiza-
tion of following exactly what was on the syllabus.
As for the Evoking process, by using the E-P-E model (Miller & Roll-
nick, 2013), I begin by eliciting from students/trainees what they already
know about the topic. What are their experiences? Perspectives? How do
they work with clients now? What do they think is important about this
topic? How does it fit into social work practice? There are many different
ways to learn about students’ thoughts, values, goals, strengths—the list
could go on. This sets the stage for a classroom or workshop that will be a
collaborative learning experience. We will all learn from one another. As I
ask these open-ended questions, I respond with the other OARS skills. Like
your clients, students are hearing themselves think out loud. This promotes
engagement—that this will be a setting where everyone’s ideas are valued
and that students/trainees are encouraged to participate.
As a trainer or teacher, while I am often guiding a discussion, some-
times I still need to provide information. Different aspects or points can be
made within the discussion that is being elicited. Because people learn in
different ways, it is helpful to hear the information (e.g., “What is reflective
listening?”), then see it demonstrated, and then witness it practiced in role
or real plays (dyad interviews using one’s own concerns). As my students
practice MI skills or whatever skills I am teaching, I provide affirmations,
coaching, feedback, and the like. All of this should be done with permis-
sion, something that often takes students aback and is sometimes hard to
remember to do. I have to resist my correcting reflex! I tend to utilize the
E-P-E model while coaching as well:
Elicit how students/trainees experienced their practice of MI skills:

• “What did you learn in this exercise?”

○ “How did you do?”
○ “If you had to do it over again, what would you do differently?”
○ “What do you need to work on to improve your skills?”
○ “What was it like to be the ‘client’ in this interaction?”
○ “What was it like to be the ‘social worker’?”
○ “How did you respond as the ‘client’?”
230 IMPLEMENTATION

The provide part may be to provide a reflection of what they said, or

an affirmation, information, or feedback of what was observed, all done
with permission. For example, I might remark:

• “You really had good eye contact and nonverbal communication

with your partner.”
• “If it is OK with you, I can tell you what I saw happen. You tended
to raise your voice at the end of your sentences, making the really
good reflections you had sound like questions.”
• “[after asking for permission to provide feedback] You followed up
your reflection with a closed question; you said, ‘Is this right?’ after
giving a wonderful reflection.”

I elicit their reactions to the material, the practice, the demonstrations,

the feedback from a direct observation—whatever we have done. Students
might be asked to apply what they have learned to their work with clients
or to think about how they can integrate and use the new skill. Like asking
a client for a commitment, I sometimes ask my trainees, “What are your
next steps?” which leads into the Planning process:

• “What will you work on this next week? How will you work on it?”
• And, the next week: “How did it go?”

Finally, feedback from students or trainees is very important to main-

tain the collaborative environment and for the trainer/teacher to respond to
students’ needs. Gillingham (2008, p. 488) proposes a model of obtaining
weekly written feedback from students, using Brookfield’s (1995) Critical
Incident Questionnaire. It is similar to what many MI trainers use at the
end of each training day:

• “When did you feel the most engaged in what was happening in
class today?”
• “When did you feel the most distanced in what was happening in
class today?”
• “What did you find the most affirming and helpful?”
• “What did you find the most puzzling or confusing?”
• “What surprised you the most?”

Many of the methods I use are not new to social work education (Abel
& Campbell, 2009). Knowing the contexts of trainees’ practice or students’
internship sites and linking what is learned to those contexts is also helpful
and individualizes application. Other aspects of being an effective teacher
 Teaching and Training MI 231

are those that also make a good MI practitioner: being motivating, encour-
aging, relational, respectful, and keeping pace with students (Edwards &
Richards, 2002; Lowman, 1996). Sounds a lot like MI spirit to me.

Future Directions

Knowledge about the structure, content, learning of, and use of MI is always
growing, as has been presented with the introduction of the four processes
and concepts around discord, introduced by Miller and Rollnick in 2013,
and the exponential amount of MI research. New knowledge about the use
of MI in different settings (micro, mezzo, and macro), with different popu-
lations, and in combination with other therapies is constantly being pro-
duced. Unique applications, such as in trauma-informed care, food insecu-
rity, and climate change awareness, presented in Chapter 11, are just some
of the many examples. Technology has entered the world of MI with online
courses and counseling via smartphone interactive applications (Nurmi et
al., 2020) and text-based conversational agents or chatbots (Liao & He,
2020). As indicated in Chapter 9, coaching and feedback around MI skills
can occur with automated, real-time assessment/coding of MI interactions
for fidelity purposes (Vasoya et al., 2019).
The application of MI has grown and changed over the years, from
being an effective intervention for those with alcohol problems to using it
to address a variety of health and other behavioral concerns and beyond.
Social work practitioners have embraced MI, as it fits so well with the eth-
ics and values of the profession and provides an evidence-based method for
communication. It can be applied across the various domains and aspects
of our work.
I hope you have found this book helpful. For readers new to MI, per-
haps you now feel this is something you would like to learn more about. For
those already familiar with MI, my goal was for you to look at MI through
the eyes of the social work profession and think about its applications in
various settings, some of which are still new to the use of MI. Perhaps you
will find some new contexts and interesting uses for MI that have yet to be
explored. As you practice and grow in your MI skills, you may find that you
approach your work differently. Believing clients can and will make posi-
tive choices and working with them from an egalitarian stance lessens our
sense of being the ones who are responsible for changing them. Your work
is centered on empowering them, guiding them to find their own answers.
Time and time again MI trainers hear anecdotal reports from trainees, that
as they integrate MI into their work they find they have more positive inter-
actions with their clients and look forward to their work with them. Give it
a try and see what happens.
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 Index

Note. f or t following a page number indicates a figure or a table.

Absolute worth, 7 client–social worker collaboration in,

Acceptance, 7 71–74
Accreditation, 11 overwhelmed client and, 69–71, 70f
Accurate empathy, 7 Agendas, organizational, 71–74
characteristics and effectiveness of, 9 Agreement with a twist strategy, 112
Adolescents, SBIRT and, 128 Alcohol, Smoking and Substance
Adult Protective Services (APS), vignette Involvement Screening Test
and dialogue example, 145–152 (ASSIST), 127
Adverse childhood experiences, examples Alcohol treatment, traditional approach
and impacts, 209 to, 26, 41
Advice giving Alcoholics, renaming of, 27
MI style of, 125–126 Alcoholism treatment, MI and, 47–48
SBIRT and, 126–128 Ambivalence
vignette and dialogue example, client, 139
130–136 decisional balance tool and, 94
Affirmations, 7, 54–55 defined, 8
characteristics of, 9 EARS and, 87–88
MI perspective on, 35–36 evoking process and, 92
African American clients; see also People American Academy of Pediatrics, SBIRT
of color recommendation of, 128
HIV diagnosis and, 186–191 American Academy of Social Work and
MI and, 13 Social Welfare, 205
Agencies, MI training in, 169–171 Amplified reflections, 111
Agenda mapping Antiretroviral therapy (ART), African
appropriate social worker guidance in, American/Latinx clients and,
74–76 186–191

275
276 Index

Asian Americans; see also People of color and information sharing and advice,
MI and, 14 130–136
Assessment, relationship with focusing, listening for, 53
76–78 mobilizing (see DARN-CAT)
Assessment trap, 108 preparatory (see DARN)
Attending skills, 49–50 responding to, 85–88
Audiotape feedback, 166–167 versus Rogers’s approach, 41
Autonomy target behaviors/focus, 40
Heart to Heart 1 sessions and, 188– Child protection services, communication
189 challenges and, 4
information sharing and, 122 Child welfare settings, agendas and,
maintaining, 71–72 71–72
reactance theory and, 199–200 Children, food insecurity in, 213–214
threats to, 107–108 Client
Autonomy support, 7 asking permission of, 124–125
collaboration with, 8
B communication challenges with, 3–4
Baer, John, 18 competence of, 121
Behavior change, MI and, 11 discussing racism with, 195–196
Behavioral goals, therapist’s approach disliked, 108
to, 30 coping with, 109–110
Bias eliciting knowledge from, 122
examples of, 185 evocation and, 8
implicit, 185 as expert, 189
unconscious, 193–194 lack of interest in, 57–59
Bigg, Dan, 131 mandated, agendas and, 71–72
Blaming trap, 108 and overwhelm from multiple issues,
Boerbaitz, Debbie, 110 69–71
Bradway, Richard, 224 responses to MI, 19–20
Bullying, MI skills and, 110 Client autonomy; see Autonomy
Burnout, MI and, 19–20, 171 Client discord, 103–119
But, avoiding use of, 55 behaviors signaling, 105
dancing with strategies of, 109–113
C in educational setting, 113–118
California Evidence-Based Clearinghouse engaging process and, 106
for Child Welfare (CEBC), 11 EPAS discussion questions, 119
Carbon footprint, MI approach to, 220 evoking process and, 106–107
Change focusing process and, 106
ambivalence about, 104–105 four processes and, 105–107
motivation to, 35 planning process and, 107
Change ruler, example using, 89–91 as social worker problem, 104
Change talk social worker reactance and, 107–109
affirmations and, 55 vignette and dialogue example,
characteristics/components of, 83– 113–118
84 Client Evaluation of Motivational
DARN-CAT and, 83–84 Interviewing (CEMI), 165
EARS for evoking, 85–88 Client feedback, 165
engaging, focusing, evoking example, Client outcomes, MI proficiency and,
94–101 171–172
as gold, 84–85 Client-centered theory, 28–31, 29t
increased, 140 Climate conversations, 221
 Index 277

Coaching Cross-cultural practice, 13–15

posttraining, 167 Cultural assessment, 198f
and skill gain maintenance, 166–168 Cultural competence
Cochrane Collaboration, 11 applications of, 193–194
Codes of ethics, 10, 11 NASW standards for, 184
Cognitive behavioral therapy (CBT), MI Cultural conversations, 196–197
combined with, 17, 18 Cultural factors, 92; see also African
Collaboration, 7 American clients; Asian
with clients, 8 Americans; Latinx clients; Native
Color-blindness, 183 Americans; People of color
as microaggression, 185 Cultural humility, 181–182, 194–196
and recognizing one’s biases, 193–194 MI spirit and, 195, 195t
systemic racism and, 186 Cultural identity, social worker
and therapist’s framework, 199 responsibility and, 200
Coming alongside strategy, 57, 112 Cultural values, Latinx, 94–101
Commitment, activation, taking steps Culture
(CAT); see DARN-CAT components of, 200
Communication and MI as learning tool, 15
directive style of, 4
guiding versus directive styles of, 5 D
social worker skills and, 3–5 DARN change talk, 83–84
Communication traps, client discord and, focus on, 140–141
108–109 DARN-CAT change talk, 83–84
Communities of practice, 168 planning and, 143–144
Compassion, defined, 7 Davis, Larry, 183
Concerns, sharing, 124–125 Death and dying, conversations about,
Confidence, evoking process and, 90–91 146
Confidence talk, 36 Decarceration, promoting, 208t
Confrontational approach to alcoholism, Decision making
26 organizational, 173–174
Congruence, 48 shared, 142–143
Conversations, cultural, 196–197 Decisional balance, 73
Corbett, Grant, 8 in evoking process, 94
Council on Social Work Education Desires, abilities, reasons, needs (DARN);
(CSWE), 46 see DARN
Counseling, cross-racial, 197 Diabetes, prevalence of, 100
Counternarrative Diabetes management, engaging,
to discrimination/racism, 186 focusing, evoking example,
HIV care and, 190–191 94–101
to systemic racism, 186 Direction, versus equipoise, 74–76
voicing, 194–202 Directive communication style, 4
Court orders Discord
agendas and, 71–72 client (see Client discord)
client ambivalence and, 87 versus resistance, 104
Crisis situations, MI and, 10 Discrepancy, instilling, 32
Critical race theory, 181–203 Discrimination, counternarrative to, 186
development of, 184 Disliked clients, 108, 109–110
EPAS 2 and, 181 Dissonance theory, 29t, 32
MI and, 182, 186–191 Diversity and difference
social work and, 183–186, 191–202 EPAS and, 182
tenets of, 184–186 rationale for focusing on, 182–183
278 Index

Domestic abuse; see Intimate violence Environmental Health Coalition,

Double-sided reflections, 111 219–220
Drinker’s Check-up, 27 Environmental justice/injustice,
vulnerable populations and,
E 218–219
EARS, and responding to change talk, Environmental social work, 207t,
85–88 218–222
Economic inequality, reducing, 208t defined, 218
Education Policy and Education Stan- Environmentum, 221
dards (EPAS); see specific EPAS EPAS
Educational Policy and Accreditation diversity- and difference-related,
Standards (EPAS), 46 181–182 (see also Critical race
Educational settings, MI in, 113–118 theory)
Educator role, 120–124 EPAS 1, 3
Eliasson, Fredrik, 176–180 client discord and, 103, 119
Elicit–provide–elicit (E-P-E) discussion questions for, 23, 65
information sharing and, 121–122, 136 engaging process and, 45
pregnancy prevention and, 123–124 EPAS 2
Empathic resonation, 51–52 client discord and, 103, 119
Empathy critical race theory and, 181, 202
defining, 48–49 discussion questions for, 65, 102
received, 54 engaging process and, 45
reflective listening and, 47–48 evoking process and, 80
Rogers’s definition of, 48 and information sharing and advice,
versus sympathy, 48 136
Empathy cycle, 49–54, 50f information sharing/advice and, 120
step 1: client speaks, 49–51 EPAS 3, environmental social work and,
step 2: empathic resonation, 51–52 223
step 3: empathy expressed thru EPAS 3, 4
reflective listening, 52–53 discussion questions for, 23
step 4: received empathy, 54 and information sharing and advice,
step 5: fresh expression, 54 136
End-of-life, conversations about, 146 information sharing/advice and, 120
Energy usage, MI approach to, 220 MI integration into social work and,
Engagement, MI definition of, 46 180
Engaging process, 45–65 EPAS 6
blocks to, 55–57 client discord and, 103, 119
brief overview, 39 discussion questions for, 65
client discord and, 106 engaging process and, 45
and defining empathy, 48–49 EPAS 6-7-8, 25
and demonstrating empathy through discussion questions for, 42
reflective listening, 47–48 EPAS 7
empathy cycle and, 49–54, 50f (see also assessment and, 76
Empathy cycle) discussion questions for, 79, 102
in MI training/teaching, 227–229 evoking process and, 80
OARS skills and, 54–59 (see also focusing and, 66
OARS skills) planning process and, 153
reactance theory and, 72 EPAS 8
and transition to focusing, 67–68 environmental social work and, 223
uninterested clients and, 57–59 and information sharing and advice,
vignette and dialogue example, 60–64 136
 Index 279

information sharing/advice and, 120 purpose of, 67–68

planning process and, 153 and transition from engaging, 67–68
E-P-E model, in MI training, 229 Food deserts, 212
Equal opportunity, achieving, 208t Food insecurity, 212–218, 213t
Equipoise, 67 conversation example, 214–217
versus direction, 74–76 groups impacted by, 212–213, 213t
Ethics, codes of, 10, 11 stigma associated with, 214
Evidence-based practice Food system, social work potential and,
social work and, 11, 13 217–218
training in, 11 Food waste, 219
Evocation, 7
from client, 8 G
Evoking process, 80–100; see also Generalist Intervention Model (GIM)
Change talk engagement and, 46
brief overview, 40 steps in, 38
change talk and, 83–94
Gonzalez, Claudia, 92
client discord and, 106–107
Grand Challenges for Social Work, 183
example with engaging and focusing,
Grief, focusing process and, 73–74
94–101
methods for, 88–94
change ruler, 89–91 H
decisional balance, 94 Harm reduction
values exploration, 92–93 defined, 129–130
Expert role, example of, 81–82 MI and, 131
Expert trap, 108 SBIRT and, 129–130
Health gap, closing, 206t
Heart to Heart (HTH1), 186, 188–189,
F
201, 208
Fajardo, Jacqueline, 31
CRT and, 191–202
Family violence, stopping, 206t
Hepatitis C (HCV), 135
Feedback
HIV diagnosis, African American/Latinx
by audiotape coding/observation,
clients and, 186–191
166–167
Homeless persons, engaging with, 58–64
client, 165
Homelessness
trainee, 230
ending, 207t
Fentanyl test strips, 133–134
and wariness of social workers, 58–59
Feteih, Sarah, 219
Fidelity measures, 162–165 Hope, finding, 35
Financial capability, building, 208t Hospice care, Navajo culture and, 16
Focus, shifting, 112 Human nature, therapist’s view of, 30–31
Focusing process, 66–79
agenda mapping and, 71–74 I
appropriate social worker guidance in, I statements, versus you statements, 53
74–76 Implicit bias, 185
assessment and, 76–78 Information sharing, 120–124
brief overview, 40 in SBIRT intervention, 126–128
client discord and, 106 vignette and dialogue example,
EPAS discussion questions for, 79 130–136
and equipoise versus direction, 74– Innovative applications, 204–224
76 environmental work, 218–222
in MI training/teaching, 229–230 EPAS discussion questions and, 223
with multiple client issues, 69–71 EPAS for, 204
280 Index

Innovative applications (continued) L

food insecurity, 212–218, 213t Labeling, avoiding, 34, 74
and Grand Challenges of Social Work, Labeling trap, 108
205, 206t–208t, 208–209 Latinx clients; see also People of color
trauma-informed practice, 209–212 cultural factors and, 92
Instilling discrepancy, 32 diabetes prevalence in, 100
Integrating MI into practice, 157–180 engaging, focusing, evoking example,
for agency group/unit, 169–170 94–101
for agency/organization, 170–171 HIV diagnosis and, 186–191
client outcomes and, 171–172 MI and, 13–14
coaching and, 166–168 Latinx students, engagement and, 47
EPAS and, 157 Learning plans, individual, 168
EPAS discussion questions, 180 Liberal bias, critique of, 192–194
field experiences, 172–180 Liberalism, CRT critique for, 185–186
Cristine Urquhart, 172–173 Libraries, engaging with homeless persons
Fredrik Eliasson, 176–180 in, 58–64
interprofessional learning Listening
experience, 174–175 in MI, 30
MI champion development and MI reflective (see Reflective listening)
CoP, 175–176 Longevity and productivity, advancing,
organizational decisions, 173–174 206t–207t
independent observation and, 162–
165
M
individual learning plans and, 168
Macro social work, 219; see also
and initial training impacts, 159–162
Environmental social work
and knowledge versus skill change,
Malnutrition-based problems, 213
158–159
Mandated clients
micro, mezzo, macro levels, 169t
agendas and, 71–72
Interviews
client ambivalence and, 87
open-ended questions in, 50–51
Medication experimentation, distrust
pretreatment, 17
related to, 189–190
structure of, 37–41, 39f
Mental health disorders, MI in treatment
Intimate violence, MI and, 17
of, 17
Involuntary client; see also Court orders;
Methadone, 134
Mandated clients
MI champion development, 175–176
planning vignette and dialogue
MI Coach Rating Scale, 163
example, 145–152
MI CoP, 175–176
supporting autonomy of, 125
MI Network of Trainers (MINT), 27, 166
working with, 109–113
and diffusion of MI training, 224–225
information about, 225
J Trainer for Trainers workshop of, 225
Japanese client, planning process and, MI training/teaching, 22–23, 27–28,
147–151 224–231
Jonesberg, Jesse, 188 client feedback and, 165
Justice, achieving, 208t computer-based applications, 164–165
Juvenile probation, directive curriculum for, 160
communication style and, 4 E-P-E model and, 229
goal of, 225
K and interprofessional learning
Khamisa, Soraiya, 77 experiences, 174–175
Kowalsky, James, 131 MINT and, 166
 Index 281

model for, 226–227, 227f Motivational Interviewing Assessment–

OARS skills in, 229 Supervisory Tools for Enhancing
organizational culture and, 160–161 Proficiency (SAMHSA), 170
skill development and, 159–162 Motivational Interviewing Competency
trainee feedback and, 230 Assessment (MICA), 163
trainer qualifications, 161 Motivational Interviewing Evaluation
Microaggressions, 185, 193 Rubric (MIER), 164
Miller, William, 26–27, 45, 47, 136 Motivational Interviewing Measure of
Motivation, client, 139 Staff Interaction (MIMSI), 165
Motivation to change, 35 Motivational Interviewing: Preparing
Motivational interviewing People to Change Addictive
characteristics of, 5–10 Behavior (Miller & Rollnick), 5
combined with other methods, 15–18 Motivational Interviewing Treatment
contraindications to, 9–10 Integrity (MITI) measure,
in crisis situations, 10 162–163, 167–168
critical race theory and (see Critical Motivations, intrinsic, 33
race theory) Multicultural counseling
criticisms of, 22–23 effectiveness of, 14–15
as cross-cultural practice, 13–15 major competencies in, 14
development of, 25–28
EPAS and (see specific EPAS) N
as evidence-based practice, 11, 13 Naloxone, 133–134
future directions for, 231 National Association of Social Workers,
innovative applications of (see Standards and Indicators for
Innovative applications) Cultural Competence in Social
integrating into social work practice Work Practice, 184
(see Integrating MI into practice) Native Americans; see also People of
interview structure, 37–41 color
processes in, 38–41, 39f MI and, 13
limitations of, 20–23 Native Americans, MI and, 13
as prelude to trauma treatment, Navajo culture, Hospice care and, 16
211–212 Nonvoluntary practitioners, 109
processes of, 38–41, 39f
real plays in trainings for, 80–83 O
relational, technical skills in, 5 OARS skills, 54–55, 54–59, 56f
research studies of, 205, 206t–208t, focusing process and, 68
208–209 and information sharing and advice,
social work principles and, 10–11, 12t 130–136
social work research on, 6t–7t in MI training, 229
spirit and components of, 7 Observation
studies of, 11, 13 independent, skill gain maintenance
training in (see MI training/teaching) and, 162–165
underlying theories of, 28–37 Older adult, planning vignette and
client-centered, 28, 29t, 30–31 dialogue example, 145–152
dissonance theory, 31 OneKeyQuestion, 124
psychological reactance theory, Open-ended questions, 50–51
36–37 Opioid use, harm reduction and, 129–
self-affirmation theory, 33, 34–35 136
self-determination theory, 31–32 Opportunistic settings, SBIRT and,
self-efficacy theory, 35–36 126–127
self-perception theory, 33–34 Organizational decision making, 173–174
282 Index

P R
Parent skills training, MI and, 18 Racial differences, discussing, 197,
People of color; see also specific groups 199–202
autonomy of, 188–189 Racism; see also Bias
as colleagues, 192 counternarrative to, 186
counternarrative and, 186 discussing with clients, 195–196
economic/social disparities faced by, as ordinary, 189–190
184 systemic, 184–185, 196
and experience with therapists, 182 White versus POC relationship with,
health care experiences of, 190 191–192
and impact of social problems, Randomized control trials (RCTs),
183–184 138–139
learning from, 193 Reactance, social worker, 36–37,
microaggressions and, 194 107–109
social contexts/cultures of, 182 Reactance theory, 29t, 36–37, 72
and social worker of different race, client autonomy and, 199–200
197, 199 climate change and, 220
systemic racism and, 185 threats to autonomy and, 104, 107–108
Personal control, emphasizing, 113 Real-play exercises, 80–83
Planning process, 138–153 Real-time Assessment of Dialogue in MI
brainstorming and, 141–142 (ReadMI), 164–165
brief overview, 40–41 Received empathy, 54
client discord and, 107 Reflections
collaborative, 141–142 amplified, 111
EPAS 7 and, 138 client discord and, 111
EPAS 8 and, 138 double-sided, 53, 111
EPAS discussion questions, 153 simple versus complex, 52–53
larger context of, 144–145 Reflective listening, 9
process of, 141–144 empathy and, 47–48
shared decision making and, 142–143, expressed empathy through, 52–54
145–152 Reframing strategy, 112
transition into, 139–141 Relational skills, 5
vignette and dialogue example, Resistance; see also Sustain talk
145–152 classic definitions of, 104
Positive regard, unconditional, 47 renamed as sustain talk, 104–105
Posttraumatic stress disorder (PTSD), Righting reflex, resisting, 57
reframing of, 210 Rogers, Carl, 5, 7, 26, 28, 29t, 30, 41,
Practitioners, nonvoluntary, 109 47–48
Pregnancy prevention, E-P-E and, Rollnick, Stephen, 27, 45
123–124
Premature focus trap, 109 S
Projects for Assistance in Transition from Screening, brief intervention, and referral
Homelessness (PATH), guidelines to treatment (SBIRT), 18
of, 58–59 harm reduction and, 129–130
Psychological reactance theory, 29t, 36–37 information sharing and, 136
PTSD, reframing as posttraumatic stress information sharing and advice and,
injury, 210 126–128
MI components in, 127–128
Q resources on, 128–129
Question–answer trap, 56–57, 78, 108 social work and, 128–129
Questions, open-ended, 50–51 steps of, 127–128
 Index 283

Self-affirmation theory, 29t, 34–35 and dislike of client, 108

Self-determination theory, 29t, 32–33 educator role of, 120–124
information sharing and, 121 race of, 192–193
Self-efficacy theory, 29t, 35–36 reactance of, 107–109
Self-evaluation, usefulness of, 164 white, reflections on racism, 187–
Self-neglect referrals, 146–147 188
Self-perception theory, 29t, 33–34 Social worker reactance, 36–37
Self-promotion trap, 109 Social workers of color; see also People of
Shaming trap, 108 color; specific groups
Shared decision making, vignette and systemic racism and, 182, 191–192
dialogue example, 145–152 Solution-focused therapy, MI combined
Shared decision making (SDM), 142–143 with, 17
Shek, Yuen Lam, 146 Standards and Indicators for Cultural
Shifting focus strategy, 112 Competence in Social Work
Skill development, training and, 159– Practice, 184
162 Stereotyping, 185
Skill gain maintenance, 162–171 Storytelling, CRT and, 186
in agency/organization, 170–171 Suboxone, 134
with coaching, 166–168 Substance Abuse and Mental Health
fidelity measures and, 162–165 Services (SAMHSA), 59
in group/unit in agencies, 169–170 Substance use
with individual learning plans, 168 harm reduction and, 129–136
Skills; see also MI training/teaching; SBIRT and, 129–130
OARS skills Substance use treatment
attending, 49–50 client backgrounds and, 51–52
communication, 3–5 MI combined with, 17
for dealing with bullying, 110 Successes, writing about, 34–35
versus knowledge, 158–159 Suicidal clients, MI and, 10
relational/technical, 5 Suicidal ideation, evoking change talk
SNAP benefits, 217 and, 72–73
Social isolation, eradicating, 207t Summaries, 54–55
Social justice, MI and, 204–205; see also Sustain talk
Innovative applications affirmations and, 55
Social problems, race-based, 183–184 decreased, 140
Social work discussing, 97
critical race theory and, 183–186 EARS for evoking, 85–88
EPAS and (see specific EPAS) MI strategies and, 111
macro, 21 questions eliciting, 33–34
nontraditional settings for, 21 versus resistance, 37
and reasons for using MI, 10 Sustain-talk statements, 27
SBIRT and, 128–129 Systemic racism, 184–185, 196
Social work practice
CRT and, 191–202 T
and recognition of racism as ordinary, Tadytin, Angel,16
189–190 Taking sides trap, 108–109
Social work schools, accreditation of, 11 Technical skills, 5
Social worker; see also Social workers of Technology, harnessing for social good,
color; White social workers 207t
biases of, 193 Therapists, microaggressions of, 185
communication skills training and, Toxic substances, distribution of,
3–5 219–220
284 Index

Translator services, 152 Veterans, working with, 228

Transtheoretical model (TTM), 38–39 Villegas, Maria, 59
Trauma
defined, 209–210 W
four R’s of, 210–211 Walker, Christopher, 228
Trauma-informed practice, 209–212 White social workers
Trust building, during engagement reflections on racism, 187–188
process, 67 reluctance to engage with, 192–193
responses to, 200–201
U systemic racism and, 191–192
Urquhart, Cristine, 172 Workplace, MI training in, 169–171
Wright, Marya, 200
V
Values card sort, 93 Y
Values exploration, in evoking process, You statements, versus I statements, 53
92–93 Youth, healthy development of, 206t