Introduction to Motivational Interviewing

1. Introduction to Motivational Interviewing Mary Clare Champion, Ph.D. Cherokee Health Systems Kentucky Primary Care Association Annual Meeting October 18, 2011 Lexington, KY

2. What is Motivational Interviewing? “Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” www.motivationalinterview.org

3. What is the spirit of this style of interaction? • Motivation comes from within client, not imposed from outside • Client is responsible, not the clinician, for identifying ambivalence • Direct persuasion is not recommended • Style is generally quiet • Clinician helps client examine and resolve ambivalence • Readiness to change is a ever-changing product of the relationship • Relationship between client and clinician is more of a partnership.

4. Goals? • Avoid creating resistance • Avoid direct arguments or direct confrontations • “If you don’t stop smoking now, you’re going to die before you’re 40.”

5. Goals • Elicit self-motivation • Patient says, “I remember having more energy when I was exercising regularly.”

6. Goals • Work to create a discrepancy between the patient’s current behaviors and their goals and values for the future • “I‘d like to feel better,” “I’d like to not take so many medicines.”

7. Assessing Motivation Keep in mind motivation should come from within, not imposed from without.

8. How important is it for you to change this aspect of your behavior on a scale of 1-10? Why not lower? What makes you want to change this aspect?

9. How ready are you to change this aspect on a scale of 1-10? Why not lower? What makes you want to change?

10. How confident are you that you can make that change on a scale from 1-10? Why not lower? What makes you want to change?

11. Why does this work? • When we ask patients to tell us why they want to change, we help them identify why they want to change. • Positive prompts help highlight positive motivation.

12. Why not more direct challenges? • Statements that challenge the patient tend to put them on the defensive. • Reactions tend to create an “us versus them” situation. • Patients are prompted to give us excuses or to tell us why they can’t/don’t want to change.

13. Listen and Reflect • Listen to patient’s responses to the above questions, then reflect answer back to them. • “It sounds to me like you’d like to make some healthier choices regarding your health, but you’re worried making those changes will be challenging.”

14. Why? • When our patients feel that we have listened to them and have heard what they are saying, they feel more understood, and can be more open to our suggestions and interventions.

15. Basic Techniques O – Open ended questions A -- Affirmations R – Reflective Listening S – Summaries Easy to remember – OARS give us power to move, especially with sustained effort

16. O – Open-ended Questions • Cannot be answered with “yes/no” • “Tell me about what brings you here today?” • “Fill me in on what’s been going on since we last met?” • “Why do you feel like it might be time for a change?”

17. A -- Affirmations • Build rapport • Must be sincere • Recognize client’s strength

18. R – Reflective Listening • LISTEN! • Vary levels – can reflect content as well as affect • Keep momentum going

19. S – Summaries • Extension of reflective listening – tell story back to client • Can build rapport, prove interest, call attention to specific pieces of story • “Let me make sure I’m getting it all… Did I miss anything?”

20. Other strategies • Typical Day • “Walk me through a normal day.” Takes attention away from just the “problem,” focus is to understand how the concern fits into daily life • Looking Back • “What was life like before this was a concern?”

21. Other strategies, cont. • Good Things/Less Good Things • Explore what sustains behavior • Avoid labeling problem if client is not in agreement • Stages of Change • Recall other changes • Give credit for necessary steps

22. Other strategies, cont. • Assessment Feedback • Can use standardized measures • Clinician provides information, client assigns meaning • Exploration of Values • Explore “ideal self,” behavioral ideals

23. Other strategies, cont. • Looking Forward • Compare visions of two futures • Exploring Importance and Confidence • How important is the change? • How confident is patient in being able to make change? • Decisional Balance • Pros/Cons of change/no change • Can do as worksheet

24. Other strategies, cont. • Change Planning • Plan for next 30/60/90 days • Can complete form together

25. Other strategies, cont. • Do it All in a Moment or Two • Brief intervention – FRAMES So, Bill you are in your third week of treatment and you’re feeling like you've accomplished everything you need to (FEEDBACK). My sense is you've begun exploring what's led to your drinking (FEEDBACK). I am concerned that you've not spent much time thinking about how you'll handle your homelife (FEEDBACK). If you asked for my advice, I would recommend you stick with treatment a little longer and work on this area (ADVICE). However, there may be other ways to do this (MENU OF OPTIONS) and the choice is really yours to make (RESPONSIBILITY). I know you've been feeling antsy (EMPATHY) and I have faith that you can make a good decision (SELF-EFFICACY). What do you think? (reprinted from www.motivationalinterview.org)

26. Traps! • Question/Answer • Can be repetitive, impede going “deeper” • Supports passivity • Confrontation/Denial • Argumentative • Repetitive • “Yes, but…”

27. Traps! • Expert • Risk of client assuming passive role • Labeling • Labels often carry stigma, and clients can resist them • Premature focus • Risk of focusing on wrong problem • Rise in resistance • Blaming • Blame isn’t issue

28. How is this different from other approaches? More confrontational approaches tend to - • assume that the person has a problem that needs to change • Offer direct advice and/or solutions • Have clinician assume authoritative role • Have information pass in unidirectional style • Rely on diagnostic labels • Have clinician behave in punitive manners

29. How am I doing? • Observe! • Is your client arguing with you? • Are you finding yourself in multiple disagreements? • Is your client ignoring you? • Is your client missing appointments?

30. Further resources www.motivationalinterview.net website maintained by MINT (Motivational Interviewing Network of Trainers) www.stephenrollnick.com

31. Questions? maryclare.champion@cherokeehealth.com