Motivational Interviewing

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1 Motivational Interviewing A Refresher Workshop Presenter: Brenda Westberry 1

2 The METHOD of Motivational Interviewing 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 2

3 Books

4 Motivational Interviewing Developed by William Miller (University of New Mexico), Stephen Rollnick (University of Wales College of Medicine), and their colleagues over the past two decades. Motivational Enhancement Therapy (MET) Transformation with self control. Commonly used for treatment of addictions. Vehicle to which MI operates- Variation of MI 4

5 The MI Foundation What is Motivational Interviewing Potential Benefits of MI within Clinical services Key MI Principles OARS-The Micro Skills Motivational Levels, Stages of Change, and Implications for Interventions The Quick Three 5

6 What is MI? Brief intervention for helping people change behavior. Aims to enhance a person s intrinsic motivation to change behavior in a highly empathetically supportive, collaborative manner with strategies for directly evoking change talk and for handling resistance skillfully. These techniques include microskills (e.g., Open-ended questioning, Affirmations, Reflections, and Summary or OARS) and strategies (e.g., creating discrepancies between a person s current behavior and his or her goals, values, or self-perceptions). 6

7 Why Be Motivational? By using motivational interventions before discussions about mandates or referrals or giving advice 1. You are better able to frame compliance with requirements in a way that matches the clients perceptions (associated with better outcomes) 2. People are more likely to feel heard and more likely to consider your recommendations. 3. If they hear and follow your recommendations (with less resistance/defensiveness), then a greater chance of compliance. Aim is to have the client hear themselves say why complying with you is important to them and how committed they are to follow through with their stated compliance intentions. Drawing out these type of statements improves the chances they comply; MI helps achieve this aim. 7

8 Why Be Motivational? Confrontation and Reactance: When our good intentions backfire. Education and Nonreception: When our direction falls on deaf ears. Being confrontational & educational may have its place, but timing is the issue AND being confrontational too early gives Clients an excuse to deflect their anger at themselves or others onto you, thereby taking the responsibility for change off themselves. So wait on the confrontation (if you re going to do it at all you may find that the MI approach is enough). Repeated attempts that primarily involve confrontation or unsolicited education to promote long-term compliance to conditions often decrease, not increase, motivation. 8

9 What Followed More than 200 clinical trials of MI have been published and efficacy reviews and meta-analyses have begun over the past three decades. Areas of concentration: target problems including cardiovascular rehabilitation, diabetes management, dietary change, hypertension, illicit drug use, infection risk reduction, management of chronic mental disorders, problem drinking, problem gambling, smoking, and mental and substance use disorders. 9

10 Spirit of MI Collaboration Compassion MI Spirit Acceptance Evocation 10

11 Reasons for MI s Popularity 1. MI is one of the most carefully defined and rigorously studied psychosocial treatments. 2. MI is a relatively brief intervention. 3. MI positively impacts engagement and retention. 4. MI has wide application to a variety of behavioral domains and populations. 5. MI is compatible with many different treatment approaches. 6. Practitioners find MI intuitively appealing and consistent with how they see themselves working. 11

12 Four Key Principles of MI: EE: Express Empathy DD: Develop Discrepancy RR: Roll with Resistance (Avoid Argumentation) SS: Support Self-Efficacy Across two phases: Building Motivation for Change Strengthening Commitment to Change MI Mindset 12

13 Applications of MI in Treatment Settings A means of rapid engagement in the general medical setting to facilitate referral to treatment. As a first session, to increase the likelihood that a client will return and deliver a useful service if the client does not return. An empowering brief consultation when a client is put on a waiting list, rather than telling a client to just wait for treatment. A help to the mandated client coerced into treatment to move beyond feelings of anger and resentment. A means to overcome client defensiveness and resistance. A stand alone intervention in settings where there is only brief contact. A counseling style used throughout the process of change. 13

14 STAGES OF CHANGE Pre- Contemplation Contemplation Determination/ Preparation Action Maintenance Relapse/Recycle 0-3 Months 3-6 Months Over 6 Months No; Denial Maybe; Ambivalence Yes, Let s Go; Motivated Doing It; Go Living It Ughh! 14

15 Pre-Contemplation People are not considering change Do not intend to change behaviors in the near future Don t realize a problem exists or are unwilling to change a behavior Do not see behavior as risky or problematic 15

16 Contemplation Individuals become aware a problem exists Perceive there may be cause for concern and reasons to change Weigh the positive and negative aspects of change 16

17 Determination Decisional balance tips in favor of change Specific planning and an examination of one s capabilities to change Set goals and begin to make commitments toward the change process 17

18 Maintenance Efforts made to sustain the gains achieved during action phase Develop and implement relapse prevention plans for targeted behavior 18

19 Action Have a strategy for change and pursue it Actively modifying habits and making changes 19

20 Roadblocks to Communication Ordering, Directing, Commanding, Warning, Threatening, Unsolicited Advice and Direction, Persuading with Logic, Arguing Lecturing, Moralizing, Preaching, Judging Criticizing, Disagreeing, Blaming, Premature or Excessive Praise, Shaming, Ridiculing, Labeling, Namecalling, Interpreting, Analyzing, Reassuring, Sympathizing, Consoling, Excessive Questioning/Probing, Being in a Hurry 20

21 The OARS Open-Ended Questions Affirmations Reflections (reflective listening) Summaries 21

22 Open-Ended Questions Are difficult to answer with brief replies or simple yes or no answers. Contain an element of surprise; you don t really know what the client will say. Are conversational door-openers that encourage the client to talk. 22

23 Affirmations: Catching Someone Doing Something Right Recognition of Effort: Client has been sober on and off for 2 months. Appreciation of Strengths: Client says I don t know if I can stop. The drugs have ruined my life but I like using them. Use of Positive Reframes: Client says: I don t want to go inpatient, I can do it on my own, things are not that bad. 23

24 Affirmations: acknowledging and recognizing the good Do NOT affirm to simply affirm or affirm with insincerity. People typically respond positively to rewards and affirmations Affirm with purpose/goal Attempt to pull someone up and remind them of their strengths What do you remember on your way home? 24

25 Forming Reflective Statements Start your reflections with the following: It sounds like you You re feeling It seems that you So you 25

26 Handling Resistance Skillfully Using Reflections Simple Reflection Amplified Reflection Double-sided Reflection Shifting Focus Reframing Emphasizing Personal Choice 26

27 Summary Statements Three or more reflections linked together Collection Linkage Transition 27

28 Exploring the Decisional Balance Pros Staying the Same Cons Pros Changing Cons 28

29 CHANGE TALK-DARN-C Desire to change: I want to complete the program Ability to change: I can stay sober Reasons to change: I want to parent my children. Need to change: I have to do this to live COMMITMENT to change: I am going into treatment Miller found that by reflecting, focusing and highlighting change talk, clients made more progress toward their goals. 29

30 Evocative Questions Desire How much do you really want to stay sober? Ability What have you done in the past to stay clean that you can try again now? Reasons Tell me about how your legal problems have negatively affected your career. Need How will your continued drug use affect your ability to see your kids? Commitment What plans do you have for getting your community service hours done? 30

31 Change Talk and Resistance Change Talk Statements Desire for Change Ability to Change Reasons for Change Need for Change Commitment to Change Resistance Statements Opposite of Change Talk statements Communication style may involve arguing, interrupting, negating, or ignoring the clinician 31

32 Readiness, Importance and Confidence Rulers-No Ruler You can simply ask: How ready, important or confident are you to make (whatever) happen? What makes you so ready, important or confident? Why not less ready, important or confident? 32

33 Engaging Focusing Evoking Planning Four Processes in MI Planning Evoking Focusing Engaging 33

34 Engaging Every relationship begins with a period of engagement. First impressions are powerful. Engaging requires that both parties establish a helpful connection and a working relationship. Factors outside of the immediate conversation can facilitate this process or undermine it. 34

35 Questions Regarding Engaging How supportive and helpful am I being? How comfortable do I feel in this conversation? How comfortable is this person in talking to me? Do I understand this persons perspective? Is this a collaborative partnership? 35

36 Focusing Focusing is the process by which you develop and maintain a specific direction in the conversation about change. Two agendas: What the person came to talk about. What they want to talk about. What the counselor wants to talk about. What changes are hoped to arise from this conversation? 36

37 Questions Regarding Focusing What goals or changes does this person really have? Do I have a different view/aspiration for change for this person? Are we working together with a common purpose? Do I have a clear sense of where we are going? 37

38 The Heart of MI. Evoking Eliciting the client s own motivations for change and involves the counselor harnessing the clients own ideas and feelings about why and how they might make these changes. 38

39 Questions regarding Evoking What are the persons own reasons for change? What change talk and I hearing? Am I steering too far or too fast? Is this about Confidence? Readiness? Or Importance? 39

40 Planning Encompasses both developing commitment to change and formulating a specific plan of action. Promoting the clients autonomy of decision making and continuing to elicit and strengthen change talk as a plan emerges. Planning is not something done once, it is an ongoing process that must be revisited. 40

41 Questions regarding Planning What would help this person to move forward? Am I remembering to evoke rather than prescribe a plan? Am I offering needed information or advice with permission? What would be a reasonable next step toward change? 41

42 The Quick 3 MI Skills Assess motivation, which is comprised of Readiness Importance Confidence Ask Open-ended Questions about clients response to this assessment WHY NOT LESS? Respond Reflectively It sounds like you re saying The way you see this problem is From your perspective, you don t feel like your anger is a problem (ER Study and Floor Ruler) 42

43 Key Endgame Questions 1. What do you think you will do? 2. What does this mean about your drinking? 3. It must be uncomfortable for you now, seeing all of this What s the next step? 4. What do you think has to change? 5. What could you do? What are your options? 6. It sounds like things can t stay the way they are right now. What are you going to do? 7. Of the things that I have mentioned here, which for you are the most important reasons for a change? How can we help? 8. What s going to happen now? Where do we go from here? 9. How would you like things to turn out for you now, ideally? 10. What concerns you about changing your use of drugs? 11. What would be some of the good things about making a change? * Based on Miller, W.R., & Rollnick, S. (1991 & 2002). Motivational interviewing: Preparing people to change (addictive) behavior. New York, NY: Guilford Press. 43

44 Useful References and Resources Clark, M. (1997). Interviewing for solutions: Strength based methods. Corrections Today, 59 (3), DiClemente, C.C., Bellino, L.E., and Neavins, T.M. (1999). Motivation for change and alcoholism treatment. Alcohol Research & Health 23 (2), Miller, W.R., & Rollnick, S. (1991, 2002). Motivational Interviewing: Preparing people for change (New York, Guilford Press). Miller, W. R. (1999). Enhancing Motivation for Change in Substance Abuse Treatment TIP Series 35. Rockville, MD: U.S. DHHS Publication No. (SMA) Rosengren, David B., Building Motivational Interviewing Skills: A Practitioner Workbook (New York, Guilford Press) 2009 www. Motivationalinterviewing.org/ 44

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