Building motivation for behaviour change: Motivational Interviewing

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1 1 Building motivation for behaviour change: Motivational Interviewing Kim Corace, Ph.D., C. Psych. Clinical Health Psychologist Division of Infectious Diseases The Ottawa Hospital Assistant Professor, Medicine and Psychology University of Ottawa February 12, 2013

2 2 Goals and Objectives How do people change behaviours? What is the natural history of change? How can we create conditions that facilitate behaviour change? How can we increase the likelihood for helping client s sustain change over time?

3 3 Imagine your most difficult client. What do difficult clients look like? How do you feel? If you wanted to increase resistance, what would you do? If you wanted to decrease resistance, what would you do?

4 4 Is Motivational Interviewing effective? MI effective in: treating alcohol and drug abuse increasing treatment adherence increasing healthy diet and exercise smoking cessation treatment of mental health problems Meta-analysis (Burke et al., 2003) found effect sizes similar to other therapies (e.g., CBT) MI produced similar results in a short time frame Stand-alone or adjunct treatment; individual or group

5 5 Case study 50 year old male client Bill Preparing for hepatitis C treatment Hepatitis C positive Problems with alcohol Drug use Lives in a rooming house Attends programming at your site and is connected to community services Wants to go on Hep C treatment, but unsure if he can commit right now because of heavy alcohol use

6 6 Stages of Change (Readiness) Maintenance: Change 6 months Pre- Contemplation Contemplation: Change date <6 months Preparation: Change date <1 month

7 7 Important stage-based questions What lifestyle habits are helping to prevent a slip back to X? How does X fit into my life? What are the good and not-so-good ways that you/others are affected by X? What plan will help you to feel more confident about changing X?

8 8 MI: 7 steps to facilitating change Lifestyle reflects a chronic state of relapse We learn how to initiate and sustain change Readiness to change is variable over time, across situations, and regulated by personally salient priorities and demands How do our programs of change accommodate this experience?

9 9 7 steps to facilitating change Clinical method is client-centered (but not directionless) Clinical focus is stage-based Clinical objective in initial phase is to build motivation for change Explore and resolve ambivalence Clinical objective in later phase is to strengthen and focus motivation on action plan

10 10 Motivation and Ambivalence Key components of motivation Perceived importance of change Self-efficacy Readiness to change Ambivalence is a natural part of the change process Resolve ambivalence to ensure change is sustained MI helps clients become unstuck in ambivalence Often clients are unaware of ambivalence

11 11 Four Principles of Motivational Interviewing 1. Express Empathy Emphasis on acceptance and reflective listening 2. Develop Discrepancy Change is motivated by discrepancy between where client is and where he/she wants to be 3. Roll with Resistance Avoid arguing for change Reluctance to make change is part of the natural change process 4. Support Self-Efficacy Reinforce belief in clientt s ability to cope and succeed in making changes

12 12 Practitioner Task: Building motivation 1. Open-ended questioning 2. Affirming / Validating 3. Reflective Listening 4. Summarizing 5. Eliciting Self-Motivational Statements

13 13 Practitioner Task: Building motivation 1. Open-ended questioning Client is actively engaged Builds relationship with client Provides a method to survey clinical issues until salient information is exhausted Use this to avoid the Question-Answer Trap Close-ended question ( yes or no to a long survey of questions) Short simple answers and no way to explore what is important to the client No opportunity for self-motivational statements Client is passive

14 14 Practitioner Task: Building motivation 2. Affirm and validate Enables the client to feel safe in disclosing or exploring salient issues 3. Reflective listening Repeating Rephrasing Paraphrasing Reflecting feelings Not listening is a road block to moving forward. Examples include: warning, giving advice, being prescriptive, shaming, questioning, disagreeing.

15 15 Practitioner Task: Building motivation 4. Summarizing Linking summaries express client s ambivalence Re-presents novel clinical insights to the client 5. Eliciting self-motivational statements What bothers you most about...? (Problem Recognition) What concerns do you/others have about...? (Concern) What do you hope to gain by changing...? (Intention to Change) What will help you to feel confident about changing..? (Optimism)

16 16 Four key questions 1. As you think about one more day, or week, or month of drinking heavily, what are the key problems that you anticipate? 2. What most concerns you (or others that are close to you) if your drinking continues to influence your daily life in the way you described? 3. If you could be ready and willing to change your drinking, what are your greatest hopes about how your life would be improved? 4. What will help you to feel hopeful and confident that you can change the way you drink?

17 17 Time-limited settings Many of us may have brief, time-limited contact with clients Motivational interviewing can be adapted for use as brief advice Critical features: Communicate respect Invite client participation and avoid being prescriptive Let the client argue for change

18 18 Importance and Confidence Scales How important would you say it is for you to change your drinking? On a scale of 0 to 10, where 0 is not at all important, and 10 is extremely important, where would you say you are? Not at all Important Extremely Important How confident would you say you are, that if you decided to change your drinking, you could do it? On a scale of 0 to 10, where 0 is not at all confident, and 10 is extremely confident, where would you say you are? Not at all Confident Extremely Confident Explore reasons why the reported value is not a 0

19 19 Conclusions Change is difficult, ambivalence is natural, and relapse is part of the change cycle Motivate for change: Develop discrepancy between where clients are and where want to be Avoid being prescriptive; let clients argue for change Use stage appropriate interventions Are you ready, willing, and able to change your practice and programs?

20 20 References MI material adapted from Nolan, RP & Corace, K.M. (2004), Doell, F. (2006; 2009) Arkowitz, H., Westra, H., Miller, W.R., Rollnick, S. (Eds; 2007). Motivational interviewing in the treatment of psychological problems. New York: Guilford Press Miller, W., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

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