Motivational Interviewing

1. Motivational Interviewing James L. Early, MD Medical Director – Via Christi Weight Management Director of Clinical Preventive Medicine – KUSM-W October 4, 2011

2. Objectives • Participants will understand the definition of motivational interviewing and the basic elements of motivational interviewing. • Participants will have an opportunity to consider where motivational interviewing may be of use to them. • Participants will briefly practice some of the motivational interviewing skills.

3. Background • Personal story • 40 years in medicine • Realization that more than biology and chemistry are needed in medicine • Realization that people look for answers from outside sources without fully exploring their own talents and resources and successes • Hunger to help people make changes that positively impact their lives and their health

4. 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.” Rollnick S and Miller WR, 1995 Behavioral and Cognitive Psychotherapy

5. Motivational Interviewing Stated in Another Way • Motivational Interviewing is working with people who are struggling with the possibility of change; and teaching motivational interviewing is working with the helpers engaged with these people in that struggle. Rosengren, D B, Building Motivational Interviewing Skills, 2009.

6. Change • We all struggle with change! • Ambivalence about change is normal • Readiness to change is not static

7. Readiness Importance Confidence

8. Prochaska’s Stages of Change Precontemplation Relapse /Maintenance Contemplation Action Preparation

9. Elements of Motivational Interviewing MI • Rosengren, D B, Building Motivational Interviewing Skills, 2009.

10. The Spirit of Motivational Interviewing • The 3 components of the MI spirit • Collaboration • A partnership is established where it is recognized that the client is also an expert on themselves, their histories and their prior efforts at change. • Evocation • The goal is to draw out from the clients their reasons and potential methods for change and to offer ideas, as appropriate, for clients’ consideration. • Autonomy • Never forget that the final decision making is left to the client. They must eventually argue for their own change.

11. The Spirits Simple Truths • Motivation for change predicts outcomes • It is an interpersonal process • It is responsive to simple acts of caring • It is responsive to brief empathic counseling • Which sometimes is enough in itself!

12. Principles of Motivational Interviewing • Rolling with resistance • Express empathy • Developing discrepancy • Support self-efficacy • R – Resist the righting reflex • U – Understand your client’s motivation • L – Listen to your client • E – Empower your client • Rosengren, D B, Building Motivational Interviewing Skills, 2009. • Rollnick S and Miller WR, 1995 Behavioral and Cognitive Psychotherapy

13. Foundational Skills - OARS • Reflective listening • Open-ended questions • Affirmations • Summaries

14. How Will the Conversation Go? • Paraphrase so they hear it twice or more if it is also later in the summary • What’s your opinion? • Pros and cons? • What do you like? • What role did the habit/behavior play in an event? • Tell me more about: • Health, wife, job, run-in with law/boss/friend

15. Eliciting Change Talk • Having your client make their own argument for a particular change is the most powerful and important thing to remember in the ambivalent client! • Often, whatever the counselors argues for is exact what the client will argue against! • “There is nothing you can’t get someone to do if you can convince them it was their idea!” • Ben Franklin

16. Change Talk and Resistence • Status quo is bad • Change is worth it • I am able to change • I am going to do it! • Status quo is OK • Change wouldn’t be worth it • It is too hard to change • I’m not planning on doing it.

17. Opening a Session/Topic • Even when you think you understand the basics of MI it can still be difficult to get the ball rolling. • How do you start a conversation, keep resistance low, build trust and create a partnership; especially when the core of the issue is very sensitive or “itchy”?

18. Key Points in Starting a Conversation • Begin with an attitude of real curiosity and a goal trying to understand more. (tobacco example) • Match your strategies to the client’s readiness to change. • Remember that being too confrontational may engender resistance! • Remember too that you are not gathering evidence to support YOUR position…you are trying to allow the client to develop within themselves an argument for change that will work for them!

19. Stages of Change and Clinical Goals Chris Dunn, PhD- personal communication University of Washington, 2011

20. Strategies for Opening a Session • Set an agenda and gently set a basic outline of the time and critical issues to be covered while allowing maximal leeway for the client to initially express his/her major concern. • A typical day is a strategy that may allow the behavior in question to arise naturally as the day is thought through. The timeline of the day may allow an opening to gently probe without seeming pushy or asking directly about “the problem”.

21. Strategies for Opening a Session • Normalizing the behavior can be an opportunity to make it clear that you are not shocked or judgmental when the client brings up a topic. Unless the “problem” is a serious and dangerous crime your primary job is to allow the client to see the issue clearly and begin to consider change. • Offering a concern is also reasonable but needs to be accompanied by any supportive statements from the client. It is critical that the client’s view and autonomy are generously included in your concern.

22. Exercises

23. Exercise #1 • The use of the “favorite teacher or motivator” • Name • Overall characteristics • What about them or their actions/personalities inspired you to do or to be your best? • How did you initially and later respond to their efforts?

24. Examples of Issues Abusive spouse – leave or stay Problem drinking – quit/cut back/not a problem Smoking – quit/cut back/not a problem Exercise – start/increase/exclude the possibility Diet – modify calories/modify quality and content/don’t address Diabetes – better control/resolve/accept current level and prevent worsening Obesity – accept as is/lose weight/lose weight only indirectly

25. Exercise #2 (a) • Client (Sarah’s husband): I’m just furious that she lied to me and had this affair behind by back. I can’t believe I didn’t see it. I feel like such an idiot. • Practitioner: In retrospect, what signs did you overlook? Thumbs UP___ Thumbs DOWN____

26. Thoughts About (a) • Thumbs down. • This is an instance where evocation and collaboration might take the practitioner in different directions. The practitioner might be better served by paying attention to the supportive aspects of collaboration first. More specifically, the practitioner missed the chance to express empathy and instead slipped into information gathering.

27. Exercise 2 (b) • Client (Arthur): I know my dad told you I’m depressed, but I’m not. Just because I don’t want to play football doesn’t mean I’m depressed. • Practitioner: Your father is worrying needlessly. What do you think he’s seeing that makes him worry this way? Thumbs UP________ Thumbs DOWN _____

28. Thoughts About (b) • Thumbs up. • Again we see collaboration and evocation present, but this time the practitioner attends to the relationship issues first. The practitioner offers a reflection, followed by an open-ended question that encourages exploration in the direction of change.

29. Exercise 2 (c) • Client (Sarah): I’ve had it with Richard's guilt mongering. Okay, so I had an affair. I’m ready to end it and start working on our marriage, but I don’t think he’s ever going to let me forget it. Maybe we should just get a divorce. • Practitioner: Sarah, you are the only one who can decide if you should stay in this marriage or leave it. I wonder what signs you would need to feel more optimistic about working on this with Richard? Thumbs UP __________ Thumbs DOWN __________

30. Thoughts About (c) • Thumbs UP. • The practitioner has acknowledged Sarah’s autonomy in making the decision about her marriage, but has also shifted the conversation toward self-exploration and optimism.

31. Let’s Walk Through the Process • Checking you motivation • Where to begin? • Stages of readiness • Express empathy and form collaboration • Listen (reflectively)(open-ended questions/affirm/summarize) • Figure out where the client is coming from and the conflict it represents • Evoke reasons and potential methods for change (client’s past) • Roll with resistance! • Empower (affirmations from conversation to that point) and support self-efficacy (support autonomy) • Elicit change talk • Seal the deal, but only when ready!

32. “It is not time that changes man, nor knowledge; the only thing that can change someone’s mind is love.” Paul Coelho eleven minutes

33. Break

34. Let’s Do It • Agree to discuss topic • make it clear that you won’t and can’t change them • “I know it is a heavy/difficult topic but can we go there?” • Explore importance and confidence • 1-10 for both • What would make the importance/confidence more or less? • Discuss action • Implementation Intention Intervention • Who, what, when and where • Close on good terms • Affirmation and summary

35. Examples of Issues Abusive spouse – leave or stay Problem drinking – quit/cut back/not a problem Smoking – quit/cut back/not a problem Exercise – start/increase/exclude the possibility Diet – modify calories/modify quality and content/don’t address Diabetes – better control/resolve/accept current level and prevent worsening Obesity – accept as is/lose weight/lose weight only indirectly

37. References • Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. Journal of Consulting & Clinical Psychology. 2003;71(5):843-61. • Emmons K, Rollnick S. Motivational Interviewing in Health Care Settings: Opportunities and Limitations. American Journal of Preventive Medicine 2001;20(1):68-74. • Resnicow K, DiIorio C, Soet J, Borrelli B, Ernst D, Hecht J. Motivational Interviewing in Health Promotion: It sounds like something is changing. Health Psychology 2002;21:444-451. • RollnickS and Miller WR, 1995 Behavioral and Cognitive Psychotherapy • Rosengren, D B, Building Motivational Interviewing Skills, 2009. • Chris Dunn, PhD – cdunn@uwashington.edu