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Motivational Interviewing: Motivating Youth to Change Behavior Training of Trainers September 21 - 23, 2008 Margaret Bavis, DNP, FNP-BC Sue Murray, RN, MPH






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Bringing Health Care to Schools for Student Success. Motivational Interviewing: Motivating Youth to Change Behavior Training of Trainers September 21 - 23, 2008 Margaret Bavis, DNP, FNP-BC Sue Murray, RN, MPH In collaboration with Sharon Stephan, PhD Center for School Mental Health.
Motivational Interviewing: Motivating Youth to Change Behavior Training of Trainers September 21 - 23, 2008 Margaret Bavis, DNP, FNP-BC Sue Murray, RN, MPH

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Slide 1

Bringing Health Care to Schools for Student Success

Motivational Interviewing:

Motivating Youth to Change Behavior

Training of Trainers

September 21 - 23, 2008

Margaret Bavis, DNP, FNP-BC

Sue Murray, RN, MPH

In collaboration with Sharon Stephan, PhD

Center for School Mental Health

Slide 2

Workshop Objectives

  • Participants will be able to name the core elements of motivational interviewing

  • Participants will be able to name at least two techniques used in motivational interviewing.

  • Participants will be able to demonstrate the steps in conducting a motivational interview session.

Slide 3

What does Motivational Interviewing look like?

Video clip

Slide 4

“Motivational interviewing was developed from the rather simple notion that the way clients are spoken to about changing addictive behavior affects their willingness to talk freely about why and how they might change.”

Stephen Rollnick, PhD

Addiction 2001; 96:1769-70.

Slide 5

Introspective Exercise #1*

What expectations do health trainees, who come into contact with clients for the first time, have about promoting behavior change among patients/clients?

*Adapted from Presentation by Edward Pecukonis, PhDUniversity of Maryland School of Social Work

Slide 6

How Does Behavior Change?

Behavior A Behavior B

Slide 7

Introspective Exercise #1 (continued)

What feelings do you experience when working with patients/clients to promote behavior change?

Slide 8

Introspective Exercise #1 (continued)

Think of a behavior you’ve tried to change

Slide 9

Introspective Exercise #1 (continued)

How much time elapsed between:

  • the first time you engaged in the behavior, and

  • the first time you recognized risk or negative consequences?

Slide 10

Introspective Exercise #1 (continued)

  • < 1 mo.

  • 1 to 3 mo.

  • 4 to 6 mo.

  • 7 to 12 mo.

  • 13 mo. to 2 yr.

  • 3 to 5 yr.

  • > 5 yr.

Slide 11

Introspective Exercise #1 (continued)

  • How much time elapsed between:

    • the first time you recognized risk or negative consequences, and

    • the first time you made an earnest attempt to change the behavior?

Slide 12

Introspective Exercise #1 (continued)

  • < 1 mo.

  • 1 to 3 mo.

  • 4 to 6 mo.

  • 7 to 12 mo.

  • 13 mo. to 2 yr.

  • 3 to 5 yr.

  • > 5 yr.

Slide 13

Introspective Exercise #1 (continued)

  • Did you ever experience some success in changing your behavior?

  • Did you ever experience a resumption of or increase in the undesired behavior after experiencing some success?

Slide 14

Introspective Exercise #1 (continued)

What conclusions would you draw from the group’s responses?

Slide 15

Possible Conclusions

  • Behavioral issues are common

  • Change often takes a long time

  • The pace of change is variable

  • Knowledge is usually not sufficient to motivate change

  • Relapse is the rule

Slide 16

Possible Conclusions (continued)

  • Our expectations of patients/clients regarding behavior change are unrealistic

  • Unrealistic expectations can lead to frustration and burn-out

Slide 17

Benefits of Learning About the Transtheoretical Model & Motivational Interviewing

  • More realistic expectations

  • Greater recognition of small accomplishments

  • Greater success over time

  • Less frustration and burn-out

Slide 18

Transtheoretical Model (Prochaska & DiClemente)

  • Individuals progress through stages of change

  • Movement may be forward or backward

  • Movement may be cyclical

Slide 19

Transtheoretical Model*

Precontemplation

Relapse

Contemplation

Maintenance

Determination

Action

SynonymsDetermination = PreparationTermination = Exit

Termination

*Adapted from Presentation by Edward Pecukonis, PhDUniversity of Maryland School of Social Work

Slide 20

Motivational Interviewing can be used at all Stages of Change:

DURING:MI can:

  • Precontemplation – raise awareness

  • Contemplation – help decision making

  • Action

    and Maintenance - enhance and remind of resolution to change

  • Relapse - enables reassessment

Slide 21

Spirit of Motivational Interviewing

  • A “way of being” with a client

  • The spirit of MI is characterized by:

    • a warm, genuine, respectful and egalitarian stance

    • supportive of client self-determination and autonomy

Slide 22

Principles of Motivational Interviewing

  • Express Empathy

  • Roll with Resistance

  • Develop Discrepancy

  • Support Self-efficacy

  • Avoid Argumentation

Slide 23

For which behaviors can we use motivational interviewing?

  • Any high risk behavior!

  • MI has been shown to be effective for:

    • Substance use

    • Tobacco use

    • Sexual activity

    • Diet and physical activity (e.g. diabetes, obesity)

    • Truancy

    • Chronic disease (e.g. asthma)

Slide 24

Motivational Interviewing with Adolescents

  • Teens: Hardwired for Risky Behaviors?

    • Emotion/Social Interaction – active in puberty

    • Behavior regulation - still maturing into early adulthood.

  • Just because we are giving teens the facts, that doesn’t mean we are changing their behavior!

Slide 25

Motivational Interviewing Techniques

Slide 26

Assessing Stage of Change

What question(s) would best assess stage of change?

Slide 27

Assessing Stage of Change (continued)

Sample initial questions:

  • How do you feel about your [behavior]?

  • What do you think about your [behavior]?

  • How does [behavior] fit into your life?

Slide 28

Assessing Stage of Change (continued)

  • Sample follow-up questions:

  • So, are you saying that you’re thinking of [changing] soon, or not really?

  • I’m confused. Are you saying that you’re ready to [change], or is this a bad time?

Slide 29

3 Stages of Techniques*

  • Opening Strategies

  • Responding to “Sustain Talk”

  • Eliciting “Change Talk”

* Adapted from New York State Office of Alcohol and Substance Abuse Services, Continuing Education, Steven Kipnis, MD, FACP, FASAM, Patricia Lincourt, LCSW, Robert Killar, CASAC

Slide 30

Opening Strategies(OARS)

  • Open-ended Questions

  • Affirmations

  • Reflections

  • Summaries

Slide 31

Opening Strategies (OARS)

Open-ended Questions

  • Close-ended question (one that can be answered yes/no/maybe): “Have you had anything to drink today?”; “Would you like to quit smoking?”

  • Open-ended question: “What is a typical drinking day like for you?”; “How do you feel about your smoking?”

Slide 32

Opening Strategies (OARS continued)

Affirmations

  • An example of an affirmation is, “I really like the way you are approaching this problem, I can see that you are very organized and logical and I am sure this will help you to succeed in our program.”

  • An affirmation can be used to reframe what may at first seem like a negative. “I can see that you are very angry about being here, but I’d like to tell you that I am impressed that you chose to come here anyway, and right on time!”

Slide 33

Opening Strategies(OARS continued)

Reflections

  • Statements made to the client reflecting or mirroring back to them the content, process or emotion in their communication.

    Reflective listening says:

  • “I hear you.”

  • “I’m accepting, not judging you.”

  • “This is important.”

  • “Please tell me more.”

  • Student: “My girlfriend gets really angry when I get stoned and pass out.”

  • Provider: “She gets mad when you do that.”

Slide 34

Opening Strategies(OARS continued)

Summaries

  • Summaries are simply long reflections. They can be used to make a transition in a session, to end a session, to bring together content in a single theme, or just to review what the client has said.

  • An example is: “Let’s take a look at what we have talked about so far. You are not at all sure that you have a ‘problem’ with alcohol but you do feel badly about your DWI and it’s effect on your family. You said that your family is the most important thing to you and you would consider totally quitting drinking if you believed it was hurting them.”

Slide 35

“Sustain-talk”

Clients may not want to make behavior changes, and many argue strongly against making these changes. They may:

  • Argue

  • Deny a problem

  • Accuse

  • Interrupt

  • Disagree

  • Passively resist though minimal answers

  • Overtly comply due to mandate with little investment

  • Become angry

Slide 36

Examples of Client Sustain Talk Statements

  • “I don’t have a problem, it is all a mistake.”

  • “I don’t drink anymore alcohol than my friends do.”

  • “This is your job. You don’t really care if I change or not.”

Slide 37

Responding to “Sustain-talk”

  • It was shown in a recent University of New Mexico study that the more, and the earlier a client argued for change in the treatment process, the better the treatment outcome.*

  • Specific techniques have been shown to decrease “resistance” or “sustain-talk.”

    *Amrheim, P., Miller, W.R. (2003)

Slide 38

Techniques for Responding to “Sustain-talk”

Reflective Techniques:

  • Simple Reflection

  • Complex Reflection

Slide 39

Simple Reflection

A simple reflection, mirrors or reflects back to the client the content, feeling or meaning of his/her communication. An example of a simple reflection to respond to “sustain-talk” is:

Client: “I know I made a mistake but the hoops they are making me jump through are getting ridiculous.”

Counselor: “You are pretty upset about all this. It seems like everyone is overreacting to a mistake.”

Slide 40

Complex Reflection

Complex reflections typically add substantial meaning and emphasis. They can provide two sides of points of view, be metaphors, or verbalize unspoken emotion. For example:

Client: “I know that I made a mistake, but the hoops they are making me jump through are ridiculous.”

Counselor: “You made a mistake and it sounds like you feel badly about that, but you also think that people are asking you to do too much.”

Slide 41

Strategic Techniques for Responding to “Sustain-talk”

Sometimes clients are entrenched or “stuck” in “sustain-talk”. In this case, there is another set of techniques referred to as strategic techniques. The strategic techniques include:

  • Shifting Focus

  • Coming Along Side

  • Emphasizing Personal Choice and Control

  • Reframe

  • Agreement with a Twist

Slide 42

Shifting Focus

Shifting focus attempts to get around a “stuck” point by simply side-stepping. An example, using the same client statement is:

Client: “I know I made a mistake, but the hoops they are making me jump through are getting ridiculous.”

Counselor: “You are upset by all of these hoops. Can you tell me more about the mistake you think you made?”

Slide 43

Coming Along Side

This technique is used to align with the client. This is used when the client has not responded with a decrease in “sustain-talk” with previous techniques. An example of coming along side is:

Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”

Counselor: “You may be at your limit and might not be able to keep up with all this.”

Slide 44

Emphasize Personal Choice and Control

Clients ultimately always choose a course of action and this technique simply acknowledges this fact. Acknowledging this can sometimes help a client recognize that they are making a choice. An example is:

Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”

Counselor: “You don’t like what others are asking you to do, but so far you are choosing to follow-through with what they are asking. It takes a lot of strength to do that. Tell me what motivates you.”

Slide 45

Reframe

This technique takes a client communication and gives it a different twist. It may be used to take negative client statement and give it a positive spin. An example:

Client: “I know that I made a mistake, but the hoops they are making me jump through are getting ridiculous.”

Counselor: “You are not happy about others having so much control, but so far you have been able to keep up with all their expectations and have been quite successful!”

Slide 46

Agreement with a twist

This is a complex technique that combines a reflection with a reframe. This gives the client confirmation that they were “heard” and then offers another perspective on their communication. It is similar to a reframe and an example is:

Client: “I know that I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”

Counselor: “You are feeling frustrated with all these expectations. You are also anxious to be successful with some things so you can keep moving forward.”

Slide 47

“Change-talk”

  • Opposite of Sustain-talk

  • Change talk is client speech that favors movement in the direction of change.

Slide 48

Examples of “Change-Talk”

  • “I really want to be a good daughter and I know I should make some changes.”

  • “I quit smoking when I decided I was ready and I think I can do this too.”

  • “I know I would be more motivated and do better in school if I cut down on my use.”

Slide 49

Techniques for eliciting “Change-Talk”

  • Exploring problem

  • Looking backward

  • Looking forward

  • Considering importance

  • Exploring values and discrepancy with behavior

  • Considering pros and cons (decisional balance)

  • Importance/Confidence Ruler

  • Exploring Extremes

  • Planning and Committing

Slide 50

Exploring Problem

  • Simply asking open-ended questions, reflecting and providing opportunity to explore the problem from the clients perspective. For example:

  • “Tell me a little more about…”

  • “What do you think about …?”

  • “Who influenced you…?”

Slide 51

Looking Forward/ Looking Backward

Ask the client to look at what life was like prior to the current problem and explore it, in order to identify potential motivators. Also, look forward to goals and plans and explore how the current problem behavior “fits” with these goals. For example:

  • “What was life like for you before this became a problem?”

  • “Tell me how you see your life two or three years from now? How might this current problem effect these goals or plans?”

  • “What kinds of things did you used to do with your time? What things do you miss?”

Slide 52

Considering Importance

Identify reasons that a change is important to the client. For example:

  • “You seem pretty committed to making a change. What motivates you?”

  • “I can see that you have been through a lot. Tell me in what ways making a change may help.”

Slide 53

Exploring Values and Discrepancy with current behavior

A conflict with values is often the strongest motivator for change. Examples include:

  • “What is most important to you?”

  • “How does your drinking effect the things in your life that you value?”

  • “When you look at your life, what are you most proud of, least proud of?”

Slide 54

Considering Pros and ConsDecisional Balance

Help the client to weigh the costs versus the benefits of the behavior in order to identify the ambivalence and move in the direction of positive change. Examples include:

  • “What are the good things about smoking pot and what are the not-so-good things?”

  • When you look at this list of pros and cons, what do you think?”

Slide 55

Importance/Confidence Ruler

Students are asked to choose a number between one and ten to describe the level of importance they perceive about changing their behavior. They are also asked to place themselves on the scale in terms of the confidence they perceive in their ability to make that change. Examples of scaling questions include:

  • “On a scale of 1-10 with 10 being the most important and 1 being the least, how important is it for you to make this change?”

  • If the client chooses a 4, a follow-up question may be- “You chose a 4, tell me why you chose a 4 and not a 3 or a 2?” Asking the question in this way encourages “change” rather than “sustain” talk.

  • “On that same scale, how confident are you that you could make a change in this behavior if you decided to?”

Slide 56

Exploring Extremes

  • The counselor asks the client to consider what is the “worst thing” that could or may happen if he/she continues with current behavior pattern.

  • Counselor can also ask what is the best thing or things that could happen as a result of a behavior change.

Slide 57

Planning and Committing

This includes talking with a client about how to make a change. Examples of questions include:

  • “If you were to decide to make a change, what steps might you take?”

  • “We have talked a lot about the reasons you think a change is important, Tell me how you will know that you are ready.”

Slide 58

Change-Plan

  • When the client has increased “change-talk” and there is little “sustain” talk this is a signal to the therapist that the client is ready to make a decision.

  • At this point, the therapist should shift to negotiating a change plan or strategy. This can be a formal exercise such as the change plan on the next slide or it can be a more informal conversation about the client’s options, desires, ideas about what might work.

Slide 59

Change Plan Worksheet

  • The changes I want to make are:

  • The most important reasons I want to change are:

  • The steps I plan to take in making this change are:

  • The ways other people can help me change are:

    Person Possible ways to help

  • Some things that could interfere with my plan are:

  • I will know if my plan is working if:

    ______________________________

    Client Signature

    ______________________________

    Counselor Signature

    (From the MET manual NIAAA clearinghouse Publication # 94-3723)

Slide 60

Motivational Interviewing Quiz!!

  • What are the general principles of MI?:

    • Express __________

    • Develop __________

    • Roll with __________

    • Support __________

    • Avoid ____________

  • What are some techniques used in MI?

Slide 61

Sustain or Change Talk?

  • “I really need to stop using or I think my girlfriend will break up with me.”

  • “My girlfriend thinks everyone has a problem because her father is an alcoholic.”

  • “I know I need to cut down, but I can do it on my own.”

  • “I feel ready to make this change and I know it will be difficult, but I have a good plan.

  • “Talking to you makes me feel worse. When can I go back to class?”

Slide 62

How can you incorporate MI into your practice?

  • Reflect on your current practice

  • Clarify roles between MH and PC providers

  • Develop protocols for incorporating MI into both mental health and primary care practice;

  • Create appointment times that accommodate motivational interviews

  • Get proper training (consult resources)

  • Practice with your colleagues (see role play)

Slide 63

Motivational Interviewing in a Brief Office Intervention

Slide 64

The BNI-ART InstituteBrief Negotiated Interview and Active Referral to Treatment

Boston, Massachusetts

Co-Directors:Edward Bernstein, MD; Judith Bernstein, RNC, PhD

Slide 65

Excellent Resource for SA MI

  • Brief Negotiated Interview and Active Referral to Treatment (BNI ART Institute)

  • http://www.ed.bmc.org/sbirt/

    • Information

    • Video clips

    • Printable handouts for students

Slide 66

1 2 3 4 5 6 7 8 9 10

The Brief Negotiation Interview

  • establish rapport & ask permission to raise subject

  • provide feedback about norms

  • enhance motivation

  • explore pros and cons

  • assess readiness to change, resilience & assets,

    • discrepancies between actual state & goals

  • develop action plan, using strengths/resources

Slide 67

The BNI for Adolescents:Using decisional balance tools, CRAFFT, and negotiating an action plan

video

Slide 68

Resources

http://www.motivationalinterview.org/clinical/

  • One-stop shop

  • Resources for clinicians, researchers and trainers

  • provide background information on the practice of Motivational Interviewing, its applications to special populations

  • Non-English speaking materials

Slide 69

Resources cont.

Enhancing Motivation For Change in Substance Abuse Treatment (TIP 35)

  • Developed by William Miller, PhD and Steve Rollnick, PhD

  • First edition available free from www.samhsa.gov

  • Second edition Motivational Interviewing, Preparing People for Change

Slide 70

Resource for Substance Abuse

Brief Negotiated Interview and Active Referral to Treatment (BNI ART Institute)

  • http://www.ed.bmc.org/sbirt

    • Screening, brief intervention and referral to treatment (SBIRT) toolkit

    • Instruction on BNI

    • Video clips

    • Printable handouts

    • Training opportunities

    • Technical assistance and consultation

Slide 71

Resource for Obesity

School Nurses, School-Based Health Centers and Childhood Overweight:

  • A report from a roundtable meeting to explore the role of school health professionals in preventing childhood overweight

  • www.healthinschools.org/Health-in-Schools/Health-Services/Schools-and-Childhood-Overweight/School-Nurses.aspx

    • Recommendations

    • Barriers

    • Sample programs

Slide 72

Contact Information

Margaret Perlia Bavis, DNP, FNP

Instructor, Community and Mental Health NursingRush University College of Nursing

Margaret_A_Bavis@rush.edu

Sue Murray, MPH, RN

Program Consultant

Illinois Coalition of School Health Centers

smurray@ilmaternal.org

Slide 73

Case Example and Role Play:Motivational Interviewing – Obesity

Slide 74

Obesity Case Example

  • Sarah is a 14 year old 9th grade student who has come to the school-based health center for a comprehensive risk assessment. Sarah is obese and at risk for Type II Diabetes (family history). She has a history of overeating and reports that she does not engage in any physical activity. She gets short of breath when walking up stairs between classes, and feels embarrassed to go to a gym or to participate in group sports even though she would like to lose weight. Her family and friends often eat at fast food restaurants, and she usually goes with them and eats unhealthy meals. Sarah has tried to diet, but her diets have not lasted longer than about a week.

  • Practice a motivational interview with Sarah focused on improving her motivation to change behaviors associated with obesity – e.g., overeating, lack of activity, eating fast food.


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