Motivational Interviewing Techniques: Reflection and Open-Ended Questions

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1 Motivational Interviewing Techniques: Reflection and Open-Ended Questions Paul F. Cook, PhD University of Colorado, College of Nursing Performance/Learning Objectives At the conclusion of this presentation, the participant should be able to: Identify principles of motivational interviewing Use reflective listening to support change efforts Use open-ended questions to elicit change talk 1

2 The Paradox People behave in ways counter to their own interests Labels (like noncompliant ) increase resistance Confronting denial increases resistance: what you resist persists Appeals to fear increase resistance Increased knowledge = behavior change Cook, 2006 What Is Motivational Interviewing? A collaborative, person-centered form of guiding, to elicit and strengthen motivation for change Miller & Rollnick,

3 Active Ingredients of Change 30% Helping Relationship 40% Self-Change Efforts 15% 15% Expectancy/ Placebo Effect Techniques Asay & Lambert, 1999 Motivational Interviewing Developed for substance abuse Intended to motivate resistant clients Based on social psychology principles Social influence/persuasion People resist your efforts to change them Person-centered counseling techniques A method for exploring and resolving ambivalence NOT: teaching, changing, controlling MI is like dancing Miller & Rollnick. (2002). Motivational Interviewing, 2 nd Ed. 3

4 The Evidence for MI Review of 30 studies with 5541 participants, most with 3-12 month follow-up data Total amount of MI provided: 30 min to 4 hrs Moderate changes in alcohol use, drug use, diet & exercise, treatment adherence (similar to longer-term counseling methods) Smaller but still significant changes for smoking (about half as strong), based on 16 studies Smaller effects for safer sex (2 studies), eating disorders (1 study) Burke, et al. (2003). J Consult Clin Psych, 71(5), ; Hettema & Hendricks. (2010). J Consult Clin Psych, 78(6), Where We Are You can t change anyone s behavior (everyone owns their own behavior) You can t teach anyone anything (adults learn when they see a need) People are helped if they feel helped (the same approach won t work for everyone) 4

5 Basic MI Techniques: OARS Open-Ended Questions Problem recognition Concern about the problem / pros and cons Optimism about change Intention to change Affirm Restate Reflect content Reflect emotion (worry, concern, upset) Reflect intention Reflect meaning (go one step further) Summarize ( what else? ) Miller & Rollnick, 2002 Conveys: interest, empathy, understanding Reflective Listening Allows the practioner to check his/her understanding of what the client meant Creates equality; as a clinician you give the expert card to the client If you notice a blind spot, the client holds all the insight into his beliefs and experiences that led him to the blind spot 5

6 Examples of Reflective Listening What I hear you saying is It sounds like You re feeling like It seems like You wish You want You think From your perspective The four-sides model Friedemann Schulz von Thun The matter layer contains statements like data and facts that are part of the news In the self-revelation layer the speaker - conscious or not - tells something about himself, his motives, values, emotions etc. The relationship layer expresses how the sender gets along with the receiver and what he thinks of him The appeal contains the desire, advice, instruction and effects that the speaker is seeking 6

7 Types of Reflective Statements Reflecting content Reflecting emotion Double-sided reflection Reflecting ambivalence Reflecting intentions Reflecting concern Your Turn You're not sure your medication is really helping your Glaucoma. You're not sure your medication is really helping your Glaucoma? What did you notice? 7

8 Reflective Listening Exercise Person #1 tell Person #2 about the best teacher you ever had Person #2 use reflective listening statements (no questions!) to find out what made Person #1 s teacher so great Resistance If the client is resistant: Often the client will reveal if she is not budging (or) upon hearing her position reflected back to her, she may reveal how open to the possibility she might be to exploring new territory for change." 8

9 Benefits of Reflective Listening Stops communication breakdown Assists in moving the session ahead even if they are not accurate Communicates respect for the client s knowledge Affirms the client s choices and reaffirms that they have the control and are in charge Open-Ended Questions Closed Questions: Do you want to exercise more? Would a support group help you eat differently? Open-Ended Questions: What are some reasons you might or might not want to be more active? Tell me what diet changes you have considered implementing with your family. 9

10 Asking Open Ended Questions What, Why, How and If.Questions Elicit more than a yes/ no or simple response Purpose is to gather information and to increase deposits in the relationship What difficulties have you had in relation to? Why or how- do you think this time will be different? If you were coaching someone else, what strategies might you offer? Answers to Open ended Questions: Increase the relationship dynamics by exploring feelings, background and beliefs. The answers share about cultural values or practices Create the space for the client to express and explore his experience, thus empowering them as the expert in his life 10

11 Open-Ended Questions Example Your Turn: Change These to Open Questions Did you watch TV last night? Did you eat tacos or salad? Do you use your medication every night? Have you had any problems using medication? Did your kids get any exercise this week? Do you keep chips in the house? Do you keep vegetables in the house? Is healthy eating a problem at family gatherings? 11

12 Open-Ended Questions Exercise Listen to the client s response (reflect twice) - and then formulate your next question You may miss a valuable opportunity to reflect empathically if you are already formulating the next question in your mind. Role Play: Tell me what seems challenging about doing Motivational Interviewing Benefits of Open Ended Questions To have the client talk more than you Creates meaning, depth, interest, ah ha! Generates ideas, problem solving, possibilities Reveals feelings and frustrations Keeps the client engaged, creates recall of your time together Eliminates DEAD AIR 12

13 Directing the Conversation Use open-ended questions to raise new topics How do you take care of your child s teeth? Where do you see opportunities for change? Use reflective listening to close topics I m hearing that you haven t had a good relationship with your dentist, and that s frustrating, so your kids aren t getting care. Follow with open-ended questions about change How can I help? Recognizing Readiness Watch for DARN CATs in the conversation: Desire for change Ability to change Reasons for change Need to change Commitment to change Activation for change Taking steps already for a change Miller & Rollnick,

14 Increasing Client Change Talk Showing Resistance Hearing more about barriers to change Strategy: be curious but don t argue Tactics: reflect, affirm concerns, elicit motivation (the strong principle of change : increase pros) Showing Readiness for Change: Hearing more about benefits of change Strategy: support goals and question methods Tactics: summarize, affirm intentions, challenge (the weak principle of change : decrease cons) Prochaska et al. (1995). Changing for Good The Relationship Matters Most Client commitment language is the best predictor of behavior change in MI The more time the client spends talking, vs. you The amount of time talking about change (desire, ability, recognition, need, commitment, activation, taking steps) Helper s interpersonal skill predicts outcome better than specific techniques Experience matters, but not specific knowledge Do whatever works to strengthen the relationship 14

15 Developing the Spirit of MI The heart of MI is a spirit of empathy acceptance respect honesty caring Empathy: 2 reflections per 1 question Hope and faith in the client Interest in others well-being and growth Moyers, Miller, & Hendrickson, 2005 Learn More about MI Rollnick, Miller, & Butler (2007). Motivational Interviewing in Health Care Rollnick, et al. (1999). Health Behavior Change MI home page: Prochaska, Norcross, & DiClemente (1995). Changing for Good Stages of change home page: Bothello (2004). Motivate Healthy Habits Seminars: 15

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