Disclosure. I have no financial relationships to discloseI will not be discussing off-label use of any medications. OUTLINE. What is Motivational Interviewing?Stages of ChangeImpact of the counselor/ health care providerPrinciples of motivational interviewingPhilosophical approachSpecific
1. Introduction to Motivational Interviewing Nimi Singh, MD, MPH
Division of Adolescent Health and Medicine
University of Minnesota Amplatz Children’s Hospital
(adapted from Kelly Lundberg, Ph.D. University of Utah)
I have no financial relationships to disclose
I will not be discussing off-label use of any medications
What is Motivational Interviewing?
Stages of Change
Impact of the counselor/ health care provider
Principles of motivational interviewing
4. Motivational Interviewing Empathetic, patient-focused directive counseling style
Seeks to create conditions for positive behavioral change
Well-suited for brief clinical encounters
Evidence-based (>200 clinical trials, both adults and adolescents)
(grounded in theory, verifiable, generalizable, delivered by wide range of health care practitioners)
5. Two Assumptions: 1. Motivation: due to interpersonal interaction (not just innate character trait)
• Confrontation leads to resistance
• Empathy and understanding lead to change
2. Ambivalence to change: normal and natural
• Competing positive and negative feelings
• Decision balance: pros and cons
6. Motivational Interviewing (con’t) Counselor/ Health care provider: facilitator
“Client/ Patient: presents arguments for change
Listens for ambivalence in patient’s own words
Reflects back negative and positive aspects of behavior AND of changing behavior
Supports client self-efficacy:
Points out strengths
Points out previous successes
Acknowledges difficulties of making behavioral change
Avoids resistance by avoiding lecturing and arguing with patient
7. Stage of Change Theory
Prochaska and DiClemente (1992)
Not even thinking about change
Wax and wane toward the idea of change
Often influenced by emotionally salient evens
Is the stage of ambivalence
Ambivalence is gone
Actual working on the change
11. MAINTENANCE “Losing weight is easy. I’ve done it hundreds of times.”
Behavior change takes repeated implementation of new life skills
Changes in the physiology of our brain takes even longer
This is often when services/ support are withdrawn
Return to the previous behavior
Once there has been a lapse or relapse, the individual re-enters at either:
13. Counselor plays KEY role in influencing re-entry point! Clients will experience shame even when there is no one blaming them
Have the conversation about how you, as a health care provider, would respond to a relapse prior to it happening
Call your clients when they don’t show for their appointment
14. Why we like working with patients in Action stage Our tools fit well with their stage of change
They cooperate and typically do what we suggest
We tend not to experience anger, frustration and impatience
We tend to feel disappointment when they don’t show for their appointment
15. Why we DON’T like working with clients in Precontemplation or Contemplation
Our tools don’t work with their stage of change
They don’t do what we suggest
We tend to experience anger, frustration and/or impatience
We tend to feel relieved when they don’t show for their appointment
We feel impotent
16. So what do we tend to do? Spend more time with clients who are in the action stage then those who are not
Use derogatory labels for those who are in the pre-contemplation or contemplation stage
Forget that ambivalence is normal
Train clients to lie to us
Shrug our shoulders and say, “I can’t help someone who doesn’t want to be helped.”
Shrug our shoulders and say, “I can’t help someone who doesn’t admit to having a problem.”
17. Who are our clients? Most of the conventional health care tools we have are for individuals who are in the Action stage
It is estimated that 30% of patients who present to clinic for care are in the Action stage (varies depending on type of clinic)
We tend to overestimate the motivation of those who say they’re ready to change and underestimate the motivation of those who indicate no interest in change.
Motivational Interviewing is the treatment of choice for AMBIVALENCE
19. PRINCIPLES OF MOTIVATIONAL INTERVIEWING
Roll with resistance
Don’t argue against it
Encourage elaboration of resistance
What makes it so hard?
What would help?
20. PHILOSOPHICAL APPROACH OF MOTIVATIONAL INTERVIEWING
Encourages “Change” talk from client
21. One of the biggest difference between MI techniques and other techniques is that the CLIENT is the one who verbalizes the need for change rather than the counselor
22. EIGHT METHODS OF EVOKING CHANGE TALK
Asking evocative questions
Using the “Importance ruler”
Exploring decisional balance
Exploring goals and values
23. ELABORATING Understand your client’s world view
Tell me about your (behavior). When did it start? When did it become a problem for you/ for others?
“How do you feel about it?”
“What do you get out of (problem behavior)?
“How do you think it causes difficulties for you?
“I can see why this must be hard for you…”
Begin to develop discrepancy between the polarized urges
So on one hand…and on the other…
Part of your wants…And the other part…
24. ASKING EVOCATIVE QUESTIONS
Evoking an emotionally “charged”/ evocative response is important for change to take place
You know your question is evocative if the client has to think about his or her response
Tone of voice is exploratory, not critical
What if you choose to continue _____?
What if you choose to decrease/ stop _____?
25. USING THE “IMPORTANCE RULER” Three parts:
On a scale of 1 to 10, 10 being “absolutely yes” and 1 being “no way”, how motivated are you to ______?
Ten is always direction you want the change to go
Sometimes it’s necessary to exaggerate the extremes
26. USING THE IMPORTANCE RULLER
Whatever number they give you, select one or two numbers BELOW and ask: Why a 6 instead of a 4?
By choosing a number below, you are eliciting change talk from the client
27. USING THE IMPORTANCE RULER Third Part:
Take a number or two above what they gave you and ask: What would it take to move you to a 7, not actually (changing the behavior), but a little more comfortable with the idea?
Be sure to elicit something the client has control over
Whatever the client tells you becomes the treatment plan.
28. USING THE IMPORTANCE RULER
Make sure the plan is something the client can actually accomplish
Work with the client exploring potential barriers to the plan and appropriate solutions
Set an appropriate time line for implementing the plan (client-directed, if at all possible)
Sometimes an appropriate plan is that the client will think about the issue.
29. USING THE IMPORTANCE RULER
Sometimes the issue is not importance or motivation, but confidence
This is often obvious when the client provides an 8 or 9 on the Importance Ruler and yet remains stuck
30. USING THE IMPORTANCE RULER
If you believe motivation has increased during a session, use the ruler again
Clients identify where they are on the ruler
Have the clients with low numbers ask the clients with higher numbers to reflect on how they got there
Have the clients with high numbers ask the clients with low numbers how they intend to move
31. QUERYING EXTREMES
Always target CURRENT behavior
What’s the worst thing about it?
What’s the best thing about it?
32. EXPLORING DECISIONAL BALANCE
Always target CURRENT behavior
Elicit pros and cons
“What do you get out of (behavior)?”
“What problems does it cause?”
33. LOOKING BACK
Always target CURRENT behavior
When was the last time _____ really made you feel good/ better/ worked for you?
The phrase “really worked for you” refers to all aspects of life
If this elicits a poignant reply, your best response is SILENCE
HARD, for us health care providers
We’re TRAINED to fix and intervene…silence often feels like failure or inaction
Often can be a powerful therapeutic tool in that it can powerfully deepen the client’s insight into the issues at hand)
34. EXPLORING GOALS (LOOKING FORWARD) AND VALUES Three Parts:
What do you see yourself doing ___ months/ years from now ( or next year)?
Do not use with individuals who :
You suspect are potentially suicidal
35. EXPLORING GOALS (LOOKING FORWARD) AND VALUES
What are your top three values and why?
Define a value if necessary
Always get three (never settle for “I don’t know” from clients)
36. EXPLORING GOALS (LOOKING FORWARD) AND VALUES
How do you think (current behavior) fits with these values?
Tone of Voice is exploratory, NOT critical
Best used following some discussion about the key issue to be changed
This technique alone has been correlated with change
It is CRITICAL to engage clients in treatment plan (especially adolescents!!!)
38. Giving information and advice Ask for permission
Qualify honoring autonomy
“Of course, while I can only suggest, you’re ultimately the one to decide…”
Ask – Provide – Ask
“….what do you think of that? Do you think that would work for you? Why? Why not?”
For suggestions, offer several, not one (otherwise it looks like the “right” answer)
39. Remember Stress physiology is often driving “problem behavior”
Make sure you/ someone on health care team is exploring stress reduction techniques with client
When stress is managed in a more healthy, pro-social way, need for problem behavior diminishes
TIPS Manual (SAMHSA)
Project Match (NIAAA)
Motivational Interviewing (Miller and Rollnick)
41. References Lundberg, KJ. “Introduction to motivational interviewing”; on-line Powerpoint presentation at: http://humanservices.slco.org/pdf/Long_MI_without_ASAM.pdf
Miller WR, Rollnick S. Motivational Interviewing: preparing people for change, 2nd ed. New York, NY: Guilford Press; 2002.
Miller WR, Rollnick S. What’s new since MI-2? Presentation in Stockholm, Sweden, June 2010 (at www.motivationalinterview.org
Prochaska, JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 1992;28:183.
Levy S, Knight JR. “Office-based management of adolescent substance use and abuse”, in Adolescent Health Care: a practical guide, 5th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2008.