Motivational Interviewing. Stephen Rollnick PhD College of Medicine, Cardiff University, WALES

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1 Motivational Interviewing Stephen Rollnick PhD College of Medicine, Cardiff University, WALES

2 What s the problem?

3 You would think that.. having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking

4 You would think that.. the very real threats of blindness, amputations and kidney failure from diabetes would be enough to motivate weight loss and glycemic control time spent in the dehumanizing privations of prison would dissuade people from re-offending

5 What s the problem? Change is complex and requires effort Your approach?

6 1. MI: Origins & essence 2. Spirit, definiion, goal, core skills 3. The new face of MI 4. Hot topics & implicaions for pracice

7 MI: origins and essence MI dialogue Story Ambivalence & the RighIng reflex

8 MI dialogue: Spot the difference She was hanging on to a lamppost outside the school gates..

9 Client: I panic, I just feel so full of shakes that I take a drink before I leave the house Counsellor: Yes it will be good to drink less. How much do drink these days? Client: Well, I m not an alcoholic its just that I need it before I leave the house Couns: How much would you say you drink each week, even if its just a guess? Client: Well you know, I don t know, I only drink wine so maybe just a few glasses a day, sometimes more; I need it to calm down really Couns: Yes, I see that s probably at least around glasses a week. Do you drink even when you go to collect the children? Client: I don t like to drink as much as I do, but when I am nervous, then I take a drink but its really not very much Couns: yes, and how often does this happen when you are with the children? Client: Well I don t always take wine before I go out to get the kids, but you have no idea how terrified I get, its like walking through a mist out there. Today I had to hang on to a lamppost to keep steady, and not faint. Its just horrible. Couns: and did you have a drink before you came out? Client: Just a little one to be honest but I m not an alcoholic you know

10 Conversation A 1. What is the counsellor s style? 2. Feelings - after that conversation: You? The client? 1. What progress is the client making?

11 Client: I panic, I feel so full of shakes that I take a drink before I leave the house Counsellor: it helps to settle your nerves Client: and I can go get the kids from school, shop and then feed them Couns: and you get quite a lot done Client: yes, those kids keep me going for hours after that, you know the food, the playing, going to bed and they are not easy, shouting all the time Couns: you ve told me about those panic attacks, how you work so hard to look after the kids, and about how you sometimes need a drink before you leave the house Client: yes, that s exactly right Couns: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you ve noticed about it? Client: well as I said, it calms my nerves, but it cant go on like this forever Couns: although it helps, you re concerned about it Client: well I m not an alcoholic you know but I cant be drinking while I am with the kids Couns: you don t want your life to revolve around drinking Client: exactly you know I must watch it

12 Conversation B MI consistent 1. What is the counsellor s style? 2. Feelings - after that conversation: You? The client? 3. What progress is the client making?

13 The primary presenting problem is panic, and its soon apparent that she also has a drinking problem. Her partner is not very supportive. One of her two sons is overactive Deficits Strengths She s a strong-willed person. She lives with her partner, and works hard to look after two very active boys. She gets fearful outdoors and sometimes uses alcohol to help her get them to school. Then she sorts out the shopping and the house...

14 COMMUNICATION STYLES Direct - Guide - Follow teach draw out listen instruct encourage understand lead moivate go along with Each style has its place Guiding is suited to helping someone change MI is derived from a guiding style

15 Origin of MI: story or two

16 CONFRONTATION You have a problem.. I m not an alcoholic Its not that bad.. You are an alcoholic; denial is part of your illness Your motivation is not high enough Yes but, I need my drink DENIAL

17 Empathic style How do you see things I must make a change Its bad, but I need my drink you want things to change You're not happy about this I m exhausted when I wake up and that s no good MOTIVATION

18 Ambivalence I m not an alcoholic Its bad Its not that bad.. Yes but, I need my drink I m exhausted when I wake up and that s no good I must make a change Sustain talk Change talk

19 ConfrontaIonal style RighIng reflex Ambivalence Evokes sustain talk (denial)

20 Empathic style Listening Ambivalence Evokes change talk (moivaion)

21 People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others. Blaise Pascal, Pensées, (1670)

22 Your role You don t have to make change happen You can t You don t have to come up with all the answers You probably don t have the best ones You re not wrestling with people Its more like a dance

23 We have inside us our own good reasons to change, and much of the strength to make it happen Its how you draw out this moivaion and strength that could improve outcomes MI involves guiding the person towards change (purposefully, respec_ully & quietly)

24 1. MI: Origins & essence 2. Spirit, definiion, goal, core skills 3. The new face of MI 4. Hot topics & implicaions for pracice

25 The SPIRIT OF MI

26 Collaboration QUESTIONS - OBSERVATIONS Compassion Acceptance Evocation

27 Goal Quietly clarify ambivalence and elicit change talk DefiniIon.a collabora5ve conversa5on style for strengthening a person s own mo5va5on and commitment to change Purposeful, focused and evoca1ve. Language about change..

28 Recognise, then highlight change talk.. and evoke more... He makes me cross. He leaves the house and says you ll be OK and its easy for him. I don t like being like this but what can I do? I feel I am about to have a heart adack and I go all dizzy, and then Open quesion: Why don t you like being like this? or ReflecIon: Youre not happy having these panic aeacks Then more change talk will follow. Predicts better outcome

29 Your task is to help the person explore - and ariculate - what s in their own true best interests. Speech influences behaviour MI is the purposeful evocaion of change talk

30 EVOKE: to elicit, summon bring out a new perspecive.. to create anew through imaginaion

31 Back to the school gates.. FIND THE CHANGE TALK

32 You: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you ve noticed about it? Client: well as I said, it calms my nerves, but it cant go on like this forever You: although it helps, you re concerned about it Client: well I m not an alcoholic you know but I cant be drinking with the kids around You: because you want to be a responsible mother Client: yes, they are my No 1 priority You: and if you drink you worry you might neglect them Client: No, never, I wont neglect them, but I get like sel?ish and I shout at them You: and that s not fair on them Client: exactly, but then I get trapped when we leave for school, I either calm my nerves with a drink or shake like a baby, and that s not good for them either, to see me like that You: like you are stuck in a corner, with no way out Client: well that s why I m here I guess, to?ind a way out You: What will be most helpful for you now? Client: to see if there is a way to get out of the house without drinking You: and to get more control over those panicky feelings Client: yes that s me, Ive got to do it differently now

33 You: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you ve noticed about it? Client: well as I said, it calms my nerves, but it cant go on like this forever You: although it helps, you re concerned about it Client: well I m not an alcoholic you know but I cant be drinking with the kids around You: because you want to be a responsible mother Client: yes, they are my No 1 priority You: and if you drink you worry you might neglect them Client: No, never, I wont neglect them, but I get like sel?ish and I shout at them You: and that s not fair on them Client: exactly, but then I get trapped when we leave for school, I either calm my nerves with a drink or shake like a baby, and that s not good for them either, to see me like that You: like you are stuck in a corner, with no way out Client: well that s why I m here I guess, to?ind a way out You: What will be most helpful for you now? Client: to see if there is a way to get out of the house without drinking You: and to get more control over those panicky feelings Client: yes that s me, Ive got to do it differently now

34 Core skills (a clearing in the forest)

35 Core Skills OARS: Open questions Affirmation Reflection Summary Offering Information and Advice

36 REFLECTION (or reflecive listening) Statements Curious hypotheses Voice intonaion down at end

37 REFLECTION (or reflecive listening) Statements Curious hypotheses Voice intonaion down at end Its Its like. You. You feel and. and you.

38 REFLECTION (or reflecive listening) Statements Curious hypotheses Voice intonaion down at end Its Its like. You. You feel and. and you. You try to capture the essence Used purposefully to evoke change talk

39 AFFIRMATION Appreciate a strength or positive action Should be both true and genuine Express positive regard and caring Strengthens engagement Diminish defensiveness You re a strong person, a real survivor

40 AFFIRMATION - some examples You're a strong person, a real survivor Despite those troubles, you got through And you tried to be honest And that wasn t easy

41 SUMMARIZE let me summarize what you ve told me so far and see if I ve missed something important. You came in because you are concerned about your panic attacks and drinking, and it scared you Engagement ++ Help with transition Keeps you focused!

42 Back to the client at the school gates Where are the core skills?

43 You: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you ve noticed about it? Client: well as I said, it calms my nerves, but it cant go on like this forever You: although it helps, you re concerned about it Client: well I m not an alcoholic you know but I cant be drinking with the kids around You: because you want to be a responsible mother Client: yes, they are my No 1 priority You: and if you drink you worry you might neglect them Client: No, never, I wont neglect them, but I get like sel?ish and I shout at them You: and that s not fair on them Client: exactly, but then I get trapped when we leave for school, I either calm my nerves with a drink or shake like a baby, and that s not good for them either, to see me like that You: like you are stuck in a corner, with no way out Client: well that s why I m here I guess, to?ind a way out You: What will be most helpful for you now? Client: to see if there is a way to get out of the house without drinking You: and to get more control over those panicky feelings Client: yes that s me, Ive got to do it differently now

44 1. DemonstraIon by Steve 2. PracIce for you

45 1. MI: Origins & essence 2. Spirit, definiion, goal, core skills 3. The new face of MI 4. Hot topics & implicaions for pracice

46 Three ediions of core text Miller W & Rollnick S Mo5va5onal Interviewing: Helping People Change, Guilford Prtess, 2012 Thanks to Jeff Allison for image design

47 The new face of MI From behaviour change to change Compassion Planning New framework 4 processes

48 PLAN How? If they want to, support them to plan changes EVOKE Why? Draw out their own good reasons to change FOCUS what change? Find a useful direction ENGAGE Shall we work together? Settle into a helpful conversation

49 Can it be MI without... Engaging? Focusing? Evoking? Planning? No No No Yes

50 It becomes MI when The style is empathic and remains so Engage AND 2. There is a target for change Focus AND 3. You are evoking the person s own motivations Evoke

51 ENGAGE FOCUS EVOKE Find a useful direction Settle into a helpful conversation PLAN If they want to, support them to plan changes Draw out their own good reasons to change

52 Rapid engagement & the 20% rule Settle into a helpful conversation ENGAGE 1. Just be nice and friendly? 2. Better & better 3. A service-wide challenge

53 ENGAGE FOCUS EVOKE Find a useful direction Settle into a helpful conversation PLAN If they want to, support them to plan changes Draw out their own good reasons to change

54 Find a useful direction FOCUS 1. Who s direction? 2. Multiple options are common 3. Agenda mapping as a skill

55 Finding a useful direcion FOCUS 1. Its obvious or 2. Options agenda mapping or 3. Unclear explore

56 Thanks to Nina Gobat for suggesting the term agenda mapping Agenda mapping FOCUS 1. Permission 2. Step back - identify topics 3. Invite person to produce new ones 4. Raise your own (including difficult subjects) 5. Agree order 6. Return to this as needed

57 ENGAGE FOCUS EVOKE Find a useful direction Settle into a helpful conversation PLAN If they want to, support them to plan changes Draw out their own good reasons to change

58 Draw out their own good reasons to change EVOKE 1. Defining heart of MI 2. Ear for language: change talk

59 Preparatory change talk (D.A.R.N.) EVOKE DESIRE to change (want, like, wish.. ) ABILITY to change (can, could.. ) REASONS to change (if.. then) NEED to change (need, have to, got to..)

60 Mobilizing Change Talk (C.A.T.S.) Reflects resolution of ambivalence EVOKE COMMITMENT (intention, decision, promise) ACTIVATION (willing, ready, preparing) TAKING STEPS

61 (Pre-) Contemplation Preparation Action

62 ENGAGE FOCUS EVOKE Find a useful direction Settle into a helpful conversation PLAN If they want to, support them to plan changes Draw out their own good reasons to change

63 If they want to, support them to plan changes PLAN 1. Righting reflex & other familiar challenges 2. Multiple routes are common 3. Path mapping as a skill

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