Motivational Interviewing: Resolving Ambivalence and Evoking Change

1. Cover MontanaMotivational Interviewing- Gina Pate-Terry, LCSW, LAC, gpateterry@mtpca.org –

2. Motivational interviewing It is an openness to a way of thinking and working that is collaborative rather than prescriptive, honors an individual’s autonomy and self-direction, and is more about evoking than installing.

3. Why don’t people change You would think…..

4. Why don’t people change • The truth is … they do… Spontaneous Remission • Positive change often occurs without formal intervention. Most people who quit smoking or recover from drug or alcohol use disorders do so without assistance from health professionals, or even from the widely available mutual-help groups. • “What is it that awakens us and causes a course correction?”

5. The proper question is not, “why isn’t this person motivated? But rather “for what is this person motivated?” ~Miller & Rollnick, 2002

6. A person-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence

8. Ambivalence • Normal in the process of change • A common and defining human experience • A precursor to positive behavioral change • Can prevent movement toward change if it is not resolved • Can be amplified and explored in order to resolve • Resolving ambivalence is the key to change, but it cannot be forced

9. Research support Over 180 Clinical Trials and over 400 Outcome Studies.

10. MI Research • Support for empathy vs. confrontation in producing positive outcomes • Support that it’s as effective as other evidenced based approaches • Support that it works in less time • Support that the method of eliciting change talk is effective • Support that it works particularly well for individuals that are angry and are least ready to change • Change is a natural process • A little motivation can lead to significant change • Can be facilitated or sped up with brief interventions

11. Motivational interviewing as a style and a spirit

12. Motivational interviewing is a style and spirit • MI Provides a different understanding from the confrontational old ways of helping people make behavior changes. • The old ways were based in a belief is that people don’t change because they haven’t quite suffered enough, that humiliation, shame, guilt are the primary engines of change. They are not. • Many individuals who struggle with behavioral changes have lived their lives suffering humiliation, shame and guilt.

13. Motivational interviewing as a style and spirit • Collaboration, not confrontation • Respect for client autonomy and choice • Affirming what they already know…It’s up to them • Sees a person’s defensiveness or resistance as a natural and/or therapeutic process, not pathological

14. Evocation • “Creation anew by way of imagination or memory” • ~Webster’s II New Riverside Dictionary

15. The interviewer Is the significant determinant adherence and outcome

16. The interviewer • Must have at least a willingness to suspend an authoritarian role, and to explore the person’s capacity rather than incapacity, with a genuine interest in their experience and perspective

17. Faith and hope Research

18. The patient’s belief about change • Ask a person how likely it is that they will succeed in making a particular change, and the answer is a reasonable good predictor of the likelihood that actual change will occur. • This phenomenon is so strong that placebo rather than no medication is the standard against new medications that must be tested • Nocebo

19. The interviewer’s belief about change • This phenomenon is not restricted to consumer’s beliefs. The interviewer’s beliefs about a person’s ability to change can become self-fulfilling prophecies as well. • Study

20. Underlying principles of motivational interviewing Express Empathy Develop Discrepancy Roll with Resistance Support Self-efficacy

21. Principle 1: express empathy - research University of New Mexico • Confrontational counseling is associated with high drop out rate and poor outcomes. • Researchers were able to predict client’s alcohol consumption 1 year after treatment from a single counselor behavior; the more the counselor confronted during treatment, the more the person drank • The clinician who has an empathetic counseling style seems to facilitate change, and its absence may deter change ~William Miller

22. Principle 1: Express empathy • Empathy is employed from the very beginning and throughout the process • Respectful listening with a desire to understand the individual’s perspective without judging, criticizing or blaming • Set aside preconceptions, diagnoses, biases, and take the person as they are in the moment

23. Principle 2.: Develop Discrepancy • MI is intentionally directive • The person being interviewed, not the interviewer should present the arguments for change • Bringing to the foreground, in a gentle way, their perspective of how things are and how things could be • Present behavior/situation vs. important personal goals and values

24. Principle 2: Develop Discrepancies • It is important to explore how the behavior may be inconsistent with the person’s goals, values, or self-perceptions. • Examples: • “On one hand…on the other hand • Ask the consumer to look into the future and imagine a changed life under certain conditions (e.g., an accident, a new diagnosis) • Ask the consumer to look back and recall periods of better functioning in contrast to the present

25. Principle 3: Roll with Resistance • Resistance is a signal to respond differently • Resistance can be reframed slightly to create a new momentum toward change

26. SA Principle 3: Roll with Resistance What does Resistance look and feel like? What is it? • A cue to change strategies • A normal reaction to having freedom/beliefs/values threatened • An interpersonal process Arguing Interrupting Negative Ignoring

27. Principle 3: Roll with resistance • WAYS TO ROLL • Reflections ( stating the consumer’s statement to convey your effort to understand their point of view) • Shift focus (changing the topic or focus to things the consumer is less resistant to exploring and changing) • Reframe (acknowledging what the consumer has said, but offering a different perspective) • Coming alongside (taking the side of no change as a way to foster the consumer’s ambivalence and elicit change talk)

28. Principle 4: support self-efficacy • Support the individual’s belief that change is possible – listen, reflect, affirm • The interviewer’s belief about a person's ability to change must be present • Increase person’s hope (looking back)

29. motivation • Resides within the person • Part of an interpersonal process • Fluctuates, dynamic, not static, can be increased and decreased • Influenced by person’s own belief in the ability to change • Influenced by interviewer’s expectation

30. Micro-skills: OARS Our First Step is to Discover the Individual’s Motivation

31. oars • O = Open-Ended Question • A = Affirm • R = Reflect • S = Summary OARS are fundamental to engaging – general practice guidelines

32. O= Open-Ended questionsIs It an Open or a Closed Question? • What do you like about smoking? • Where did you grow up? • Isn’t it important for you to have meaning in your life? • Are you willing to come back for a follow-up visit? • What brings you here today? • Do you want to stay in your relationship? • Have you ever thought about walking as a simple form of exercise? • How do you feel about not being insured?

33. Is It an Open or a Closed Question • In the past, how have you overcome an important obstacle in your life? • Would you like to set your quit date? • What possible long-term consequences of diabetes concern you most? • Do you care about your health? • What are the most important reasons why you want to stop smoking? • Will you try this for 1 week? • Is this an open or a closed question?

34. Affirm • Affirmations are genuine, direct statements that are usually directed at something specific and change oriented that the individual has done. • These statements demonstrate that the interviewer understands and appreciates at least part of what the patient is dealing with, and is supportive of the patient as a person

35. Affirming examples • I appreciate your honesty (if you know she is being honest) • I can see that staying fit is important to you • It shows commitment to come in to see me today • You have some good ideas

36. reflections • Listening reflectively and forming reflections is one way to be empathetic. Listening reflectively is about being quiet and actively listening to the client, and then responding with a statement that reflects the essence of what the patient said, or what you think the patient meant. • You accurately identify the essential meaning of what the patient has said and reflect back in terms easily understood by the patient • Your inflection at the end of the reflection is downward • You pause sufficiently to give the patient an opportunity to respond to the reflection and to develop the conversation • Your reflections often increase the time spent talking by the client, foster a collaborative tone, and reduce resistance.

37. Examples of reflective statements • Simple Reflection • Patient: She is driving me crazy trying to get me to quit. • Interviewer: Her methods are really bothering you • Patient: I don’t have anything to say. • Interviewer: You’re not feeling talkative today

38. summary • Summaries communicate that you have tracked what the individual has said and that you have an understanding of the big picture • Help structure an interview so that no one gets too far away from important issues. • Can help you link what a person said to something they offered earlier

39. Summary example • “So, Sally, let me make sure I have got this right. You care about your health very much, and you don’t want to chance having an medical issue cause you or your family financial harm. You believe you need to sign up for insurance, and at the same time you feel the monthly payments would be hard to manage. Is that right?”…or…what else would you add?”

40. Eliciting change talk

41. Change talk The goal of change talk is to get the patient to argue for change.

42. Eliciting change talk • Eliciting change talk, or self motivational statements, is a crucial component and primary goal when using a MI approach. It differs from OARS in that it is more directive. Using OARS will help keep you afloat and may help steer you in directions you and the client want to go, but it may not get you to the final destination. Eliciting change talk is a strategy to help establish and resolve ambivalence and move forward.

43. Eliciting change talk • How would you like your life to be different? • What would be the good things about changing? • What is the best thing you can imagine if you do change? • What would you be willing to try? • Of all of these options, which ones sound like a good fit for you? • What might be the next steps?

44. The darn-c • D = Desire • A = Ability • R = Reason • N = Need • C = Commitment Level

45. D = Desire statements.. Statements indicating a desire to make a change Examples: • “I’d like to have insurance pay for my medications.” • “I wish I could make my life better.” • “I want to take better care of my self.” • “Having insurance would make me feel so much better about myself.”

46. A = Ability statements • Examples: • “I think I could afford…..” • “That might be possible.” • “I’m thinking if I cut back on buying fast food, I might be able to manage.” • “If I had someone to help me, I could probably budget it. • Statements that speak to the consumer’s self-efficacy or belief in the ability to make changes.

47. R = Reasons statements Statements that reflect the reasons the client gives for considering a change. • Examples: • “To stay healthy, I should probably have insurance • “My husband is going to leave me if I don’t stop drinking.” • “I don’t think being uninsured is a good example for my kids.” • “I want to take better care of my kids.” • “Getting in shape would make me feel so much better about myself.”

48. N = Need statements Statements that indicate a need for change. These can be similar to R statements, but the emphasis is more affective or emotional than a more cognitive R statement • Examples: • “It’s really important to my health keep an eye on my blood pressure.” • “Something has to change or I will worry myself into a tizzy.” • “I could have diabetes like my dad and not know it.” • “I’d like to quit drinking if I could.” • “I wish I could make my life better.”

49. C = Commitment Statements Commitment language is the strength of change talk. • Examples: • “I might be able to make it happen” • “I could consider signing up” • “I will sign up”.

50. EARS - Responding to Change Talk • Elaborating • Affirming • Reflecting • Summarizing