A Brief Introduction to Motivational Interviewing

A Brief Introduction to Motivational Interviewing Stephen Pont, MD, MPH Ava Wood, MSN, RN, NEA-BC Texas Center for the Prevention and Treatment of Childhood Obesity Dell Children s Medical Center April 9, 2011

Objectives Become familiar with core themes of motivational interviewing Understand benefits and applications of motivational interviewing

History MI debuted in 1983 as an intervention for problem drinkers. In 1991, the first text on MI was published with William Miller and Stephen Rollnick as authors.

Initial research studies focused on adult behavioral change for alcohol, drugs, and smoking. Subsequent studies included obesity and children and adolescents.

Evidence Based Ruback, Sandboek, Lauritzen, and Christian, 2005 Evaluated 72 randomized controlled trials with MI as the intervention Meta-analysis demonstrated positive effect of MI in all the studies

How do we currently promote change with our patients?

Insight

Knowledge

Skills

What it s NOT Not a Trick Not a Theory Not Psychotherapy Not a Panacea Not for Everyone or Every Situation

Motivational interviewing has been shown to be an effective strategy for behavioral change.

Convincing Exercise Client: considering a change Interviewer Convince and persuade speaker to make this change

Convincing Exercise Interviewer: Suggestions: These are the reasons why you should make this change. Why don t you just do it? The excuses you are giving just don t make sense. You re just stalling. Well, just do it this way

Convincing Exercise How did the client feel? Judged, pressured, resistant, arguing against the change How did the interviewer feel? Tension, difficult conversation

Motivational Interviewing a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. - Miller & Rollnick, 2002

Motivational Interviewing Client centered Patient has the responsibility Partner with the patient Directive Seek to resolve ambivalence Guiding toward specific topics, exploring patient s point of view, and targeting certain aspects of patient s statements Resolve ambivalence Move towards positive change Elicit change talk

Applications of MI Risk Behaviors Alcohol and other drug addictions Smoking HIV risk behaviors Eating disorders Adopting healthy behaviors Physical activity Fruit and vegetable consumption

Spirit of Motivational Interviewing Belief in the individual To use their own energy and insight to discover the best solutions for themselves Uses good counseling skills Unconditional positive regard Genuineness Empathy Acknowledges There may be strong reasons why a person maintains a particular behavior

Common Approach to Behavior Change Advice Can elicit resistance, especially when unwelcome Information Knowing what to do weakly correlated with actually doing a behavior Motivation People vary in level of motivation Style must match motivation

Common Approach vs. Spirit of MI Confrontation Education Authority Collaboration Evocation Autonomy

Spirit of Motivational Interviewing Collaboration We have expertise, the patient is the expert Evocation Eliciting, not just telling Discover the motivation for change from within the person and evoke it Autonomy Only the client can decide Curiosity, not authority

Target: Ambivalence Lack motivation Feel 2 ways about an issue Try to avoid conflict Yes I m interested, but

Target: Ambivalence Arguing for one side causes the patient to defend the other As the status quo is defended, the likelihood of change decreases Talk themselves out of considering change

4 Motivational Interviewing Principles Roll with resistance Express empathy Develop discrepancy Support self-efficacy

4 Motivational Interviewing Principles Roll with resistance Express empathy Develop discrepancy Support self-efficacy R E D S

1) Roll with Resistance Dance, don t wrestle Goal is for patient to generate the reason for change Is a behavior, not a personality trait Can be created or lowered by the way that we interact with patients Roll with Resistance Express Empathy Develop Discrepancy Support Self-efficacy

1) Roll with Resistance We create it by: The righting reflex Making suggestions / telling what to do Trying to convince them to change Predicting dire outcomes Providing info without permission Disagreeing with what the patient sees as important Roll with Resistance Express Empathy Develop Discrepancy Support Self-efficacy

1) Roll with Resistance We address it by: Reflections Shifting focus Emphasize patient is in control Obtain permission then provide information and opinions Acknowledge what the patient sees as important Roll with Resistance Express Empathy Develop Discrepancy Support Self-efficacy

2) Express Empathy Never judgmental Never condescending Reflective listening Roll with Resistance Express Empathy Develop Discrepancy Support Self-efficacy

3) Develop Discrepancy How does current behavior synch with future goals Try to understand why they are ambivalent Seek change talk to increase their perceived discrepancy Roll with Resistance Express Empathy Develop Discrepancy Support Self-efficacy

4) Support Self Efficacy Enhance confidence so patient believes change is possible Open questions focusing on ability Personal strengths History of previous successes Trouble shooting potential problems, saboteurs and solutions Roll with Resistance Express Empathy Develop Discrepancy Support Self-efficacy

Resolving Ambivalence Change talk! DARN-C Desire: want, prefer, wish Ability: able, can, could, possible Reasons: specific arguments for change Need: important, have to, got to Commitment: going to, will

Resolving Ambivalence Change talk! DARN-C Desire: want, prefer, wish Ability: able, can, could, possible Reasons: specific arguments for change Need: important, have to, got to Commitment: going to, will Predicts change

Elicit Change Talk People become more committed to doing what they actually say Help them talk themselves into change They argue for change not you Facilitate client statements of Optimism about being able to change Intentions to change

Elicit Change Talk Don t dwell on exploring ambivalence if they re ready to change Have them describe how change will look and work What are benefits of making this change What would be your first step What would your plan look like

Getting the Conversation Started OARS Open-ended questions Affirmations Reflective listening Summaries

MI Video Example What was good? What could be better?

Getting the Conversation Started OARS Open-ended questions Affirmations Reflective listening Summaries

Ask Open-Ended Questions No yes or no answers Should results in a dialogue Ask one question at a time Use respondent s own words, when possible Examples: Tell me about.. Help me understand.. To what extent.. Open-ended questions Affirmations Reflective Listening Summaries

Batting Practice

Affirmations Statements recognizing client strengths Must be genuine not contrived Builds rapport Increases self-esteem and selfefficacy Open-ended questions Affirmations Reflective Listening Summaries

Reflective Listening "Reflective listening is a way of checking rather than assuming that you know what is meant." - Miller & Rollnick, 1991 Open-ended questions Affirmations Reflective Listening Summaries

Reflective Listening A fundamental of MI Seek to understand your client s frame of reference When patients feel understood, more likely to discover inner motivation and self-efficacy Must listen carefully in order to reflect Reflections focus on client s change talk Open-ended questions Affirmations Reflective Listening Summaries

Some (safe) Reflections The basics It sounds like you are feeling.. It sounds like you are not happy with. It sounds like you are having trouble with.. These may initially feel awkward You re not ready to. You re having a problem with. You re feeling that. It s been difficult for you. Open-ended questions Affirmations Reflective Listening Summaries

Types of Reflective Listening Content You see a connection between your inactivity and being overweight and getting diabetes Feelings You are scared that if you don t do something about your weight now you will end up like everyone else in your family with diabetes Meaning Your children are important to you and you want them to be healthy and learn from your example Open-ended questions Affirmations Reflective Listening Summaries

Batting Practice Reflective Listening Exercise

Some (safe) Reflections The basics It sounds like you are feeling.. It sounds like you are not happy with. It sounds like you are having trouble with.. These may initially feel awkward You re not ready to. You re having a problem with. You re feeling that. It s been difficult for you. Open-ended questions Affirmations Reflective Listening Summaries

Summaries Let me see if I understand what you ve told me so far.. Focus on client s statements regarding Problem recognition Reasons for change For ambivalence, summarize pros & cons Optimism confidence about change Ask for feedback about your summary: What have I missed? Open-ended questions Affirmations Reflective Listening Summaries

Use Importance/Confidence Ruler On a scale of 1 to 10, how important is it to you to if 1 is important at all and 10 is very important 1 3 5 7 10 Not at all Very Important Important

Use Importance/Confidence Ruler Why did you chose a 6 and not lower number like, 4? They now must state positive reasons for their choice

And now a word from the founder of MI What were some techniques used? Did they go well?

Ready for Change Get a commitment How likely will you act on this? 3 or lower indicates ambivalence Patient formulates a plan Who will be supportive? Who may create challenges? How will change look? What will be exciting about making the change?

Summary Show respect, empathy Do more listening than talking Recognize the patient s autonomy Solutions reside within your clients Their motivation Their behavior Their values and goals Their personal expertise