Motivational Interviewing 201: Addressing Behavior Change

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1 Motivational Interviewing 201: Addressing Behavior Change Texas Behavioral Health Institute Jim Sacco, M.S.W., L.C.S.W. July

2 Assessing Readiness-Stage-Based Intervention PRECONTEMPLATION RELATIONSHIP-BUILDING Find out about your consumer s agenda. Try to make connections between their agenda and yours. Inquire politely and neutrally about his/her goals. Improve self-efficacy Give positive feedback about all of client s survival techniques, strengths, and acknowledge the difficulties s/he has had. Ask what others are concerned about and explore why they are concerned only IF it seems that the client would not be alienated by your pursuing this line of questioning. If you can pursue this, you can then listen for and empathize with the client s feelings. Inquire politely and neutrally about the client s thoughts Have you ever thought about Non-coercive education i.e., give information neutrally have you ever heard that..? Universalize Some people.... CONTEMPLATION RELATIONSHIP BUILDING Explore positive history with current behavior find out what is positive about current use. Stay neutral OR weigh in on the side of NO change validate that change will be a challenge. Develop discrepancy help client to seethe gap between goals and current behaviors. You may plant a seed but should be acutely aware about coercion or manipulation of the situation. Don t attempt to move too fast. Work the Decisional Balance thoroughly explore the pros and cons. Invite your consumer to explore the possibility of change with phrases like o What would it be life if..? o What would you miss? o What is it like when?] o What do other people say about..? o What do you know about..? Highlight ambivalence So, on the one hand..,, but on the other... PREPARATION Begin the process of planning for change. Ask about barriers. This helps assure that the plan is realistic and addresses obstacles. Consider important, small, initial concrete steps. Discuss previous attempts. Build on what has worked before. Offer suggestions in the third person [e.g. Some of my clients have tried ]. Ask about social support [e.g. Who can help you ]. Use your instincts about setting a start date. When the time is right, elicit commitment. Motivational Interviewing 1

3 ACTION Take right-sized steps, to minimize the possibility of failure. Explore how is this working? and be prepared to problem-solve. Explore social support for more adaptive behavior. Consider this as a chance to refine the plan. Discuss results. MAINTENANCE Choose support system that is personally and culturally relevant! Explore how is this working? Discuss positive benefits of change. Ask about triggers [e.g. Are you ever tempted to ]. RECYCLE View relapse as a learning opportunity. Ask about what lead to relapse. Ask about what was working. This is not starting from square one, but refining based on previous experience. Minimize shame and blame BLAME THE PLAN! Adapted from: Jeannie Little, LCSW Harm Reduction Therapy Center Motivational Interviewing 2

4 Review of MI Processes: PLAN EVOKE FOCUS ENGAGE PROCESS ONE: Engage: Spirit plus Core Skills Spirit of Motivational Interviewing *Partnership *Autonomy /Acceptance *Compassion *Evocation Core Skills Open Questions- Questions that explore who, what, how, etc. Affirmations- Finding strengths, praising attempts, building self-efficacy Reflective Listening- Careful listening to find motivation, resolve ambivalence Summaries- Focusing on priority content and feelings Motivational Interviewing 3

5 Spirit and CORE Skills Practice- Observer Feedback Form Modeling Spirit Partnership Autonomy Compassion Evoking Behavior Counts Skills Open Questions Affirmation Reflective Listening Summaries Motivational Interviewing 4

6 Process Two: FOCUSING Find a Shared Goal Patient CCNC Providers Motivational Interviewing 5

7 Focusing Techniques Agenda setting Finding a focus Eliciting the client s agenda Is there anything you would like to do for your health in the next week or two? Brief Action Planning Miracle question Offering a menu Information/Feedback Bubble sheet Asking permission to discuss your agenda Would it be all right if we also talked a bit about...? What is the focus, the change goal for MI? [Aim for a shared goal?] Get permission/qualify, honoring autonomy Ask Provide Ask [offer multiple suggestions] Patient s Dilemma Patient s Goals/Values Possible Consequences Motivational Interviewing 6

8 Patient Dilemma and Bubble Sheet Practice - Observer Feedback Form Modeling Principles Conveys Empathy Finds Shared Goal-Negotiates Agenda Highlights Patient Dilemma Dancing not Wrestling with Ambivalence Behavior Counts Skills Open Questions Affirmation Reflective Listening Summaries Motivational Interviewing 7

9 Brief Action Plan The Eight Clinical Competencies of BAP: Three Questions and Five Skills BAP is organized around three core questions and five skills delivered with the Spirit of MI. The flow chart displayed in Figure 1 presents an overview of the key elements. The three questions are highlighted in blue and the five skills are shown in yellow and green. The three questions and the yellow skills are applied during every BAP interaction, while green skills are used when clinically indicated. Figure 1. Brief Action Planning Flow Chart Motivational Interviewing 8

10 BUBBLE SHEET Motivational Interviewing 9

11 Process Three: Evoking ELICITING CHANGE TALK- Evocative Questions Benefits of Changing Consequences of Not Changing Intention to Take Action Optimism about the Future RESPONDING TO CHANGE TALK When you hear change talk, don t just sit there! Normally in MI one would respond in one of four ways, represented by the acronym EARS: ''Explore''. Ask for elaboration: how, in what ways, why? Ask for examples: when was the last time this happened (e.g., for an adverse consequence). ''Affirm''. Express agreement, appreciation, encouragement, etc. ''Reflect''. This is the most common response to change talk to offer a simple or complex reflection. ''Summary''. Change talk is also collected in bouquet summaries. Motivational Interviewing 10

12 Change Readiness Importance- How important is the behavior change to me? + > READINESS Confidence- How confident am I that I can make the change? USING RULERS Ask, "On a scale from zero to ten, how important is it to you to [target change] where zero is not at all important, and ten is extremely important? Follow up: And why are you at and not [one number lower]? What might happen that could move you from to [one number higher]? The follow-up is to ask How confident you are that you could and follow up with the same scale. Ask how you can help increase confidence. Be prepared to Intervention Approaches: Building Readiness Enhancing Importance Building Confidence * * * * * * * * * * * * * * Motivational Interviewing 11

13 Process Four: PLANNING 1) Invite patient s solutions. 2) Offer additional resources. 3) Address barriers/reinforce benefits. 4) Assess social support. 5) Assess skills deficits and address these know referrals. 6) Negotiate time line. 7) Assess level of ongoing support. 8) Internal/external referrals. Next Steps Keep Practicing Read/Study [Using MI in Health Care; MI 3 rd edition] View [You Tube: search MI or S-BIRT] Supervision Small Groups Tapes/Observation Motivational Interviewing 12

14 Change Plan Worksheet-60 day Plan The Change I want to consider is: My main goals in making this change are: These are some possible obstacles to change and how I could handle them: Possible Obstacles: How to respond: I plan to do these things to accomplish my goals: Specific Action When? Other people could help me with change in these ways: Person Possible ways to help: I will know that my plan is working when I see these results: Motivational Interviewing: Second Edition Miller and Rollnick, 2002 Motivational Interviewing 13

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