PRINCIPLES OF MOTIVATIONAL INTERVIEWING

1
PRINCIPLES OF MOTIVATIONAL INTERVIEWING
2
Problems with standard practice

• Unwelcome advice elicits resistance
• Knowledge insufficient to change behavior
• Individuals vary in their motivation

3
MI Key Principles

• Motivation elicited from the patient not imposed
  from without
• Persuasion is not effective
• Clinician directs patient to examine and resolve
  ambivalence
• Readiness is not a patient trait but is a product
  of the interaction
• Therapeutic relationship is a partnership not
  expert/recipient

4
Key MI Clinician Goals

• Express Empathy - through acceptance and
  reflective listening
• Develop Discrepancy - between current behavior
  and hopes for the future
• Avoid Argumentation - and direct confrontation
• Roll with Resistance
• Support Self-efficacy and optimism
• Minimize problem-solving and advice giving

5
MI in practice

• Get permission to proceed
• Use open ended (starting) questions
• (Get the ball rolling)
• Use reflective listening
• (Keep discussion going, express empathy)
• Develop discrepancy
• Roll with resistance

6
Getting permission

• When Getting Started/When Offering Advice or Info
• Id like to spend a few minutes talking about
  your eating habits/smoking/cholester
  ol level
• Is that ok with you?
• May I share some strategies with you that other
  people have found helpful
• Give a menu of options

7
Open ended questions

• Cant be answered yes/no
• Respondent has to use own words
• Not biased
• Only use to initiate discussion
• Never more than 3 in a row

8
Open ended questions examples

• I see from your chart that you state factually
• smoke about 1/2 a pack a day
• are drinking about 4 drinks a day
• dont appear to be taking you BP pills everyday
• How do you think this is affecting your health?
• What do you make of this?
• Tell me about your.exercise habits/diet/drinking
• To what extent.
• How often
• Help me understand.

9
Reflective listening

• Core MI skill much more effective than
  questioning
• Statement, not a question
• Hypothesis testing
• If I understand you correctly it sounds like...
• Affirms and validates Express Empathy
• Avoids Arguing
• Rolls with Resistance
• Keeps the patient thinking and talking

10
Reflective listening examples

• It sounds like you feel overwhelmed when...
• It sounds like this has been tough for you...
• It sounds like you have mixed feelings
• It sounds like youre not ready to.
• Etc.

11
Reflective listening levels

• Increasing depth
• Restate same words
• Rephrase slightly different words
• It sounds like (responding to content)
• Paraphrase interpret, infer meaning
• Deduce connect the dots
• You feelbecause. (responding to meaning)
• Summative review and synthesize

12
Developing discrepancy

• The Columbo Approach
• Hmm... Help me figure this out. Sometimes when
  you drink during the week you cant get out of
  bed to get to work. Last month you missed 5 days.
  But you enjoy your work, and doing well in your
  job is very important to you.
• Highlight discrepancy between important value
  and behavior

13
Rolling with resistance

• Simple reflection
• Amplified reflections
• I dont know why my wife is worried about this, I
  dont drink anymore than my friends do.
• So your wife is worrying needlessly.
• Double-sided reflections
• I know smoking is bad for me and you want me to
  give it up, but Im not going to do that
• You can see that there are some real problems
  here, but youre not willing to think about
  quitting altogether
• Shift focus

14
MI demonstration
15
Brief MI Oriented counseling in Medical Practice

• Identify behavior issue
• Get permission to proceed
• Assess motivation (0-10)
• REFLECT
• Assess confidence (0-10)
• REFLECT
• Discuss past experience
• REFLECT
• Summarize
• Close the deal

16
Brief MI Oriented counseling in Medical Practice
contd

• Motivation and Confidence Rulers
• You said a 5 - thats a lot higher than a 1, so
  youve been thinking about this - what makes you
  that motivated?
• You said a 5 - thats a good bit lower than 10 -
  what keeps you from being a 10?/ OR What would
  need to happen for you to get from from X to
  (higher number)?

Motivation On a scale of 1 to 10, with 10 being
very motivated, how motivated are you to quit
smoking? 1 2 3 4 5 6 7 8 9 10 Not at all
Somewhat Very
17
Brief MI Oriented counseling in Medical Practice
contd

• Discuss Past Tries
• What have you tried to do in the past about
  _________?
• What might help this time around?
• Let patient come up with solutions first
• Get permission to offer advice
• Offer alternatives

18
Brief MI Oriented counseling in Medical Practice
contd

• Summarize discussion
• Remember patients reasons for change
• Summarize their statements (negatives then
  positives)
• Let me see if I understand what youve told me
  so far (end with) What have I missed?
• You mentioned that you were worried about _____
  and your family said ____. You are afraid it
  will be hard, but you ________

19
Brief MI Oriented counseling in Medical Practice
contd

• Close the deal
• Be sensitive to degree of readiness to change
• After summarizing negatives then positivesSo
  where does that leave you?
• So overall it sounds like you are interested in
  working on this problem, what would you like to
  do next/work on first?
• It sounds like this is going to be difficult for
  you but Im wondering if you might consider
  taking a small step toward change?
• Given what youve told me so far it sounds like
  you might be ready to try quitting - how can I
  help with that?

20
Brief MI Oriented counseling in Medical Practice
- An Exercise

• Behavior ____________
• Identify behavior issue
• Get permission to proceed
• Assess motivation
• Assess confidence
• Discuss past experience
• Summarize
• Close the deal

21
Useful References

• Miller Rollnick (1991). Motivational
  Interviewing Preparing people to change
  addictive behavior. The Guilford Press New York.
• Rollnick S., Butler C.C., Stott N. (1997).
  Helping smokers make decisions the enhancement
  of brief intervention for general medical
  practice. Patient Education and Counseling, 31,
  191-203.
• Rollnick S., Miller W.R. (1995). What is
  motivational interviewing? Behavioural and
  Cognitive Psychotherapy, 1995, 23, 325-334.
• DHHS (1999). Motivational Interviewing as a
  counseling style. In Enhancing Motivation for
  Change in Substance Abuse Treatment Treatment
  Improvement Protocol (TIP) Series 35. DHHS
  Publication No. (SMA) 99-3354, Rockville, MD.