Motivational Interviewing: A Key to Behavior Change

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Motivational InterviewingA Key to Behavior
Change

• Jewish Community Services
• December 10, 2009

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Agenda

• Overview
• Motivation and readiness to change
• Definition and principles of MI
• History and empirical support
• Practical applications
• Skills and Strategies
• Relational and technical skills
• Eliciting and responding to change talk
• Rolling with resistance
• Information exchange
• Moving toward change

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(No Transcript)
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Something Ive been thinking about changing but
havent changed yet!
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How ready are you right now to change?

• 1 2 3 4 5 6 7
  8 9 10
• Not at all Somewhat ready
  Completely
• ready ready

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Persuasion

• Speaker
• Something Ive been thinking about changing
• Counselor 
• Give at least three specific benefits that would
  result from changing
• Tell the speaker how to change 
• Emphasize the negative consequences of not
  changing
• Tell the speaker to do it. 
• If you meet resistance, repeat the above
• PS This is NOT Motivational Interviewing!

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The Righting Reflex
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Common Reactions to Righting

• Angry
• Oppositional
• Discounting
• Defensive
• Justifying
• Not understood
• Not heard
• Procrastinate

• Afraid
• Helpless, overwhelmed
• Ashamed
• Trapped
• Disengaged
• Not come back avoid
• Uncomfortable
• Agitated

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Listening

• Speaker
• Something Ive been thinking about changing
• Counselor 1
• Do NOT give any advice! Ask, and listen with
  interest
• What do you think you will enjoy about making
  this change?
• How might you go about it, in order to succeed?
• What are the three best reasons to do it?
• What concerns you most about what will happen if
  you dont make this change?
• There will be a Counselor 2, so pay attention!

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Summarizing

• Counselor 2
• Summarize
• Desire to change
• Ability to change
• Reasons to change
• Need to change
• Ask
• So, what do you think you will do?
• Speaker
• Respond naturally

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Common Reactions to Listening

• Understood
• Accepted
• Want to talk more
• Liking the counselor
• Open
• Respected
• Engaged
• Able to change

• Safe
• Empowered
• Hopeful
• Comfortable
• Interested
• Want to come back
• Cooperative

Would you rather work with these people . . . . .
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or these?

• Afraid
• Helpless, overwhelmed
• Ashamed
• Trapped
• Disengaged
• Not come back avoid
• Uncomfortable
• Agitated

• Angry
• Oppositional
• Discounting
• Defensive
• Justifying
• Not understood
• Not heard
• Procrastinate

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MI Spirit

• A utonomy-support client is responsible for
  choosing and carrying out change acceptance that
  the client may choose not to change
• C ollaboration negotiation with the client and
  avoidance of an authoritarian stance. Dual
  expertise
• E vocation emphasis on drawing out the clients
  ideas

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a constructive discussion about behavior change

• Rollnick, S et al. (1999) Health behavior change
  A guide for practitioners. New York Churchill
  Livingstone

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What is MotivationaI Interviewing?

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

Miller WR Rollnick S (2002). Motivational
interviewing Preparing people for change (2nd
ed). New York Guilford.
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Principles of MI Guiding clients toward change

• Express Empathy
• Develop Discrepancy
• Roll with Resistance
• Support Self-efficacy

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A Good Guide Will

• ASK the person where he/she wants to go, and get
  to know him/her a bit
• LISTEN to and respect what the person wants to do
  and offer help accordingly
• INFORM the person about options and see what
  makes sense to them

Rollnick, Miller, Butler, 2007
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History of MI

• Alternative to confrontation in addictions
  treatment, based on
• Research findings
• Clinical experience
• Humanistic psychology
• Diffusion of innovation
• Addiction treatment
• Medical settings
• Corrections
• Social services

Miller WR Rollnick S (2002) Miller (2006)
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• Observable behavior
• Within the persons control
• Where motivation is at least part of the problem

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Empirical Support

• Decrease problematic behavior
• Increase beneficial behavior
• Caution findings are mixed
• Briefer but not better than credible alternatives
• Most valuable as add-on or prelude
• Beneficial when patients are resistant/angry

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Maintenance
Action
Preparation
Contemplation
Precontemplation
Stages of Change
Prochaska JO et al. (1992). American
Psychologist, 47, 1102-1114.
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Putting it all together MI in practice

• Motivational Interviewing as a counseling style
• MI-based brief interventions
• Sandwich or assessment-based intervention
• Checkup or feedback-based intervention
• Behavior-oriented single-session or brief
  intervention
• MI adapted for special settings, populations
• Medical settings
• Case management
• MI in groups
• Clients with severe mental illness

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Skills and Strategies
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MI Microskills

• Open Questions
• Affirmations
• Reflective Listening
• Summaries

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OARS Client-Centered AND Directive
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Client-Centered

• Ask questions to understand the clients
  perspective on the topic
• Use reflective listening to show that you are
  listening

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and Directive

• Phrase questions to elicit change talk
• When you hear change talk
• Reflect
• Ask for elaboration
• Summarize
• Sustain talk may also be elicited as part of
  the process of exploring ambivalence
• Use summaries to guide the direction of the
  conversation

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Change Talk

• D esire to change
• A bility to change
• R easons to change
• N eed to change
• C ommitment to change and taking steps toward
  change

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How it works Technical Hypothesis

• MI decreases resistance
• Resistance predicts lack of behavior change
• MI increases change talk
• Change talk predicts behavior change

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Change talk and behavior changePreliminary
findings

• Preparatory change talk (DARN) predicts
  commitment
• Increasing strength of commitment predicts
  behavior change
• End of session is important!

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How it worksRelational Hypothesis

• Clinician empathy and MI Spirit predict behavior
  change

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Soccer Mike
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Open Questions

• Closed Questions
• Yes/no
• Factual information
• Clinician is in charge
• Open Questions
• Broad latitude in response
• Shared responsibility

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Good question!

• Getting started Setting the agenda
• Scaling questions (rulers)
• Decisional balance (pros and cons)
• Exploring goals and values
• Looking forward, back
• Key questions moving toward the next step
• What do you make of all of this?
• What might be a first step for you?
• What, if anything, do you plan to do?
• What will you do?

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Setting the Agenda

• What brings you here today?
• How can I be most helpful to you today?
• Would it be OK with you if we talk about HIV
  risk?
• We can talk about employment, housing, or child
  care. Where would you like to begin?

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Agenda-Setting Chart
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Importance/Confidence

• How important is it for you right now to change?
• On a scale of 0 to 10, what number would you give
  yourself?
• 0 .. 10
• not at all
  extremely
• important important
• Why are you at x and not at 0?
• What would need to happen for you to get from x
  to y?

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Importance/Confidence

• If you did decide to change, how confident are
  you that you could do it?
• 0 .. 10
• not at all
  extremely
• confident confident
• Why are you at x and not at 0?
• What would need to happen for you to get from x
  to y?
• How can I help you get from x to y?

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Responding to Change Talk

• E laborating
• A ffirming
• R eflecting
• S ummarizing

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Elaborating

• In what way?
• Can you give me an example?
• What else?
• What does that mean to you, personally?
• How specifically?

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Affirming

• Catch the client doing something right
• Client Effort - recognize even small steps toward
  change
• Client Strengths (Traits) - recognize clients
  ability to change
• Interesting and admirable
• qualities - recognize clients as
• people and not just clients

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Thinking Reflectively

• Speaker
• One thing I like about myself is
• An accomplishment that I am proud of
• The best advice I ever got was
• Listeners
• Do you mean that you?
• Speaker
• ONLY yes or no

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Forming Reflections

• Make a guess about what the person means
• BUT, form a statement, not a question!
• Think of your question
• Do you mean that you . . . ?
• Cut the question words
• Do you mean that You . . .
• Inflect your voice down at the end
• Theres no penalty for missing
• In general, a reflection should not be longer
  than the persons statement.

X
X
X
X
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Forming Reflections

• Speaker
• One thing I like about myself is
• Listeners Reflective listening
• You
• Speaker
• Yes or No AND elaborate
• Continue until listeners understand speakers
  intended meaning

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Summaries

• Gather up your understanding of clients
  situation and experience
• Useful for changing direction of the conversation
• Bouquet of flowers

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The Client From Heck
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Wrestling With Ambivalence

• Counselor argues for change
• Persuades
• Suggests, Advises
• Client argues for staying the same
• RESISTANCE

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Confrontation-Denial Trap

• Youre an alcoholic and have to stop drinking or
  else you are going to die!
• Im not, you cant make me, and everyone has to
  die sooner or later!

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Dancing With Ambivalence

• Counselor empathizes with status quo
• Client explores options for change

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Client always makes the argument for change
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People are generally better persuaded by the
reasons which they have themselves discovered
than by those which have come into the mind of
others.

• Pascal, Pensées, 1660

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Reflective Responses to Resistance

• Simple
• Amplified
• Double-Sided

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Hot Potato

• Speaker shares one difficult resistant statement
  from real world practice
• Group members brainstorm reflective responses
• Continue until everyone has had a chance to be
  the speaker

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Additional Responses to Resistance

• Shifting focus
• Emphasizing personal control
• Reframing

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Directive

• Increase importance of change
• Personal feedback Lab tests, diagnostic
  assessments, relationship of behavior to
  presenting problem, etc.
• Information about the nature of the problem
• Increase confidence for change
• Personal feedback Strengths and skills
• Information about strategies, resources

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and Client-Centered

• Dont forget the relationship!
• Elicit-Provide-Elicit

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Interpersonal Skills for Informing

• Slow down
• Remember Its a person
• Consider the clients priorities
• Positive messages matter
• Consider the amount of information
• Ask permission, or qualify to respect autonomy
• Remember to ask and listen

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Elicit - Provide - Elicit

• ELICIT clients ideas
• Knowledge, goals, strategies, skills
• PROVIDE feedback or information
• Just the facts
• ELICIT clients reactions
• What do you make of this?
• How does this fit with?
• Does this make sense?
• How confident are you that you can do this?
• REFLECT clients reactions!

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2 Phases of MI

• PHASE 1 Increasing Readiness
• Focus on why of change
• General sense of ability to change
• PHASE 2 Strengthening Commitment
• Focus on how of change
• Specific change plan

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The MI Sandwich

• MI-Style Assessment
• What brings you here today?
• Standard Assessment
• Biopsychosocial history
• Fill out the forms
• MI-Style Discussion and Clinic Orientation
• Summary of what youve told me
• Where would you like to go from here?
• Provide relevant information

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Feedback-Based Intervention Motivational
Enhancement Therapy
Assessment
Feedback Use MI style to discuss
Negotiate Change Plan
Follow-up
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Focused Intervention

• Open the encounter
• Set the agenda
• Assess readiness
• Explore ambivalence
• Ask about next steps
• Provide information as needed
• Close the encounter

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MI in Practice

• This fits great! I will try
• This looks like a good idea, but will need some
  work to fit. I will explore

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For More Information

• www.vanhornconsulting.com
• Click on resources for searchable resource
  blog

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Deborah H. A. Van Horn, Ph. D

• Deborah H. A. Van Horn, Ph. D., LLC
• 297 Westwood Drive, Suite 105
• West Deptford, NJ 08096
• [phone]
• dvh_at_vanhornconsulting.com
• www.vanhornconsulting.com