1

Motivational Interviewing:Motivational Interviewing: Motivating Youth to Change BehaviorMotivating Youth to Change Behavior

Training of TrainersTraining of TrainersSeptember 21 - 23, 2008September 21 - 23, 2008

Margaret Bavis, DNP, FNP-BCMargaret Bavis, DNP, FNP-BCSue Murray, RN, MPHSue Murray, RN, MPH

In collaboration with Sharon Stephan, PhDIn collaboration with Sharon Stephan, PhDCenter for School Mental HealthCenter for School Mental Health

Bringing Health Care to Schools for Student Success

2

Workshop ObjectivesWorkshop Objectives

1) Participants will be able to name the core elements of motivational interviewing

2) Participants will be able to name at least two techniques used in motivational interviewing.

3) Participants will be able to demonstrate the steps in conducting a motivational interview session.

3

What does Motivational What does Motivational Interviewing look like?Interviewing look like?

Video clip

4

“Motivational interviewing was developed from

the rather simple notion that the way clients are

spoken to about changing addictive behavior

affects their willingness to talk freely about why

and how they might change.”

Stephen Rollnick, PhD

Addiction 2001; 96:1769-70.

5

Introspective Exercise #1*Introspective Exercise #1*

What expectations do health trainees, who come into contact with clients for the first time, have about promoting behavior change among patients/clients?

*Adapted from Presentation by Edward Pecukonis, PhDUniversity of Maryland School of Social Work

6

How Does Behavior Change?How Does Behavior Change?

Behavior A Behavior B

7

Introspective Exercise #1 Introspective Exercise #1 (continued)(continued)

What feelings do you experience when working with patients/clients to promote behavior change?

8

Introspective Exercise #1 Introspective Exercise #1 (continued)(continued)

Think of a behavior you’ve tried to change

9

Introspective Exercise #1Introspective Exercise #1 (continued)(continued)

How much time elapsed between:the first time you engaged in the

behavior, andthe first time you recognized risk or

negative consequences?

10

Introspective Exercise #1Introspective Exercise #1 (continued)(continued)

• < 1 mo.

• 1 to 3 mo.

• 4 to 6 mo.

• 7 to 12 mo.

• 13 mo. to 2 yr.

• 3 to 5 yr.

• > 5 yr.

11

Introspective Exercise #1 Introspective Exercise #1 (continued)(continued)

How much time elapsed between:

the first time you recognized risk or negative consequences, and

the first time you made an earnest attempt to change the behavior?

12

Introspective Exercise #1 Introspective Exercise #1 (continued)(continued)

• < 1 mo.

• 1 to 3 mo.

• 4 to 6 mo.

• 7 to 12 mo.

• 13 mo. to 2 yr.

• 3 to 5 yr.

• > 5 yr.

13

Introspective Exercise #1 Introspective Exercise #1 (continued)(continued)

Did you ever experience some success in changing your behavior?

Did you ever experience a resumption of or increase in the undesired behavior after experiencing some success?

14

Introspective Exercise #1 Introspective Exercise #1 (continued)(continued)

What conclusions would you draw from the group’s responses?

15

Possible ConclusionsPossible ConclusionsBehavioral issues are commonChange often takes a long timeThe pace of change is variableKnowledge is usually not

sufficient to motivate changeRelapse is the rule

16

Possible Conclusions Possible Conclusions (continued)(continued)

Our expectations of patients/clients regarding behavior change are unrealistic

Unrealistic expectations can lead to frustration and burn-out

17

Benefits of Learning About the Benefits of Learning About the Transtheoretical Model & Transtheoretical Model & Motivational InterviewingMotivational Interviewing

More realistic expectationsGreater recognition of small

accomplishmentsGreater success over timeLess frustration and burn-out

18

Transtheoretical Model Transtheoretical Model (Prochaska & DiClemente)(Prochaska & DiClemente)

Individuals progress through stages of change

Movement may be forward or backward

Movement may be cyclical

19

Transtheoretical Model*Transtheoretical Model*

Determination

Relapse

Precontemplation

Contemplation

Maintenance

Action

TerminationSynonyms

Determination = PreparationTermination = Exit*Adapted from Presentation by Edward Pecukonis, PhD

University of Maryland School of Social Work

20

Motivational Interviewing can be Motivational Interviewing can be used at all Stages of Change:used at all Stages of Change:

DURING: MI can:– Precontemplation – raise awareness

– Contemplation – help decision making

– Action and Maintenance - enhance and remind

of resolution to change

– Relapse - enables reassessment

21

Spirit of Motivational InterviewingSpirit of Motivational Interviewing

A “way of being” with a client

The spirit of MI is characterized by:– a warm, genuine, respectful and egalitarian

stance– supportive of client self-determination and

autonomy

22

Principles of Motivational Principles of Motivational InterviewingInterviewing

Express EmpathyRoll with ResistanceDevelop DiscrepancySupport Self-efficacyAvoid Argumentation

23

For which behaviors can we use For which behaviors can we use motivational interviewing? motivational interviewing?

Any high risk behavior! MI has been shown to be effective for:

– Substance use

– Tobacco use

– Sexual activity

– Diet and physical activity (e.g. diabetes, obesity)

– Truancy

– Chronic disease (e.g. asthma)

24

Motivational Interviewing with Motivational Interviewing with Adolescents Adolescents

Teens: Hardwired for Risky Behaviors?– Emotion/Social Interaction – active in puberty– Behavior regulation - still maturing into early

adulthood.

Just because we are giving teens the facts, that doesn’t mean we are changing their behavior!

25

Motivational Interviewing Motivational Interviewing TechniquesTechniques

26

Assessing Stage of ChangeAssessing Stage of Change

What question(s) would best assess stage of change?

27

Assessing Stage of Change Assessing Stage of Change (continued)(continued)

Sample initial questions:How do you feel about your

[behavior]?What do you think about your

[behavior]?How does [behavior] fit into your

life?

28

Assessing Stage of Change Assessing Stage of Change (continued)(continued)

Sample follow-up questions:So, are you saying that you’re

thinking of [changing] soon, or not really?

I’m confused. Are you saying that you’re ready to [change], or is this a bad time?

29

3 Stages of Techniques*3 Stages of Techniques*

Opening Strategies

Responding to “Sustain Talk”

Eliciting “Change Talk”

* Adapted from New York State Office of Alcohol and Substance Abuse Services, Continuing * Adapted from New York State Office of Alcohol and Substance Abuse Services, Continuing Education, Education, Steven Kipnis, MD, FACP, FASAM, Patricia Lincourt, LCSW, Robert Killar, CASAC

30

Opening StrategiesOpening Strategies(OARS)(OARS)

Open-ended QuestionsAffirmationsReflectionsSummaries

31

Opening Strategies Opening Strategies ((OOARS)ARS)

Open-ended Questions Close-ended question (one that can be

answered yes/no/maybe): “Have you had anything to drink today?”; “Would you like to quit smoking?”

Open-ended question: “What is a typical drinking day like for you?”; “How do you feel about your smoking?”

32

Opening Strategies Opening Strategies (O(OAARS continued)RS continued)

Affirmations An example of an affirmation is, “I really like the way

you are approaching this problem, I can see that you are very organized and logical and I am sure this will help you to succeed in our program.”

An affirmation can be used to reframe what may at first seem like a negative. “I can see that you are very angry about being here, but I’d like to tell you that I am impressed that you chose to come here anyway, and right on time!”

33

Opening StrategiesOpening Strategies(OA(OARRS continued)S continued)

Reflections Statements made to the client reflecting or mirroring back to them the

content, process or emotion in their communication.

Reflective listening says: “I hear you.” “I’m accepting, not judging you.” “This is important.” “Please tell me more.”

Student: “My girlfriend gets really angry when I get stoned and pass out.”

Provider: “She gets mad when you do that.”

34

Opening StrategiesOpening Strategies(OAR(OARSS continued) continued)

Summaries Summaries are simply long reflections. They can be used to

make a transition in a session, to end a session, to bring together content in a single theme, or just to review what the client has said.

An example is: “Let’s take a look at what we have talked about so far. You are not at all sure that you have a ‘problem’ with alcohol but you do feel badly about your DWI and it’s effect on your family. You said that your family is the most important thing to you and you would consider totally quitting drinking if you believed it was hurting them.”

35

““Sustain-talk”Sustain-talk” Clients may not want to make behavior changes, and

many argue strongly against making these changes. They may:

Argue Deny a problem Accuse Interrupt Disagree Passively resist though minimal answers Overtly comply due to mandate with little investment Become angry

36

Examples of Client Sustain Talk Examples of Client Sustain Talk StatementsStatements

“I don’t have a problem, it is all a mistake.” “I don’t drink anymore alcohol than my friends

do.” “This is your job. You don’t really care if I

change or not.”

37

Responding to “Sustain-talk”Responding to “Sustain-talk”

It was shown in a recent University of New Mexico study that the more, and the earlier a client argued for change in the treatment process, the better the treatment outcome.*

Specific techniques have been shown to decrease “resistance” or “sustain-talk.”

*Amrheim, P., Miller, W.R. (2003)

38

Techniques for Responding to Techniques for Responding to “Sustain-talk”“Sustain-talk”

Reflective Techniques:Simple ReflectionComplex Reflection

39

Simple ReflectionSimple Reflection A simple reflection, mirrors or reflects back to the

client the content, feeling or meaning of his/her communication. An example of a simple reflection to respond to “sustain-talk” is:

Client: “I know I made a mistake but the hoops they are making me jump through are getting ridiculous.”

Counselor: “You are pretty upset about all this. It seems like everyone is overreacting to a mistake.”

40

Complex ReflectionComplex Reflection Complex reflections typically add substantial

meaning and emphasis. They can provide two sides of points of view, be metaphors, or verbalize unspoken emotion. For example:

Client: “I know that I made a mistake, but the hoops they are making me jump through are ridiculous.”

Counselor: “You made a mistake and it sounds like you feel badly about that, but you also think that people are asking you to do too much.”

41

Strategic Techniques for Strategic Techniques for Responding to “Sustain-talk”Responding to “Sustain-talk”

Sometimes clients are entrenched or “stuck” in “sustain-talk”. In this case, there is another set of techniques referred to as strategic techniques. The strategic techniques include:

Shifting Focus Coming Along Side Emphasizing Personal Choice and Control Reframe Agreement with a Twist

42

Shifting FocusShifting Focus

Shifting focus attempts to get around a “stuck” point by simply side-stepping. An example, using the same client statement is:

Client: “I know I made a mistake, but the hoops they are making me jump through are getting ridiculous.”

Counselor: “You are upset by all of these hoops. Can you tell me more about the mistake you think you made?”

43

Coming Along SideComing Along Side This technique is used to align with the client.

This is used when the client has not responded with a decrease in “sustain-talk” with previous techniques. An example of coming along side is:

Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”

Counselor: “You may be at your limit and might not be able to keep up with all this.”

44

Emphasize Personal Choice and Emphasize Personal Choice and ControlControl

Clients ultimately always choose a course of action and this technique simply acknowledges this fact. Acknowledging this can sometimes help a client recognize that they are making a choice. An example is:

Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”

Counselor: “You don’t like what others are asking

you to do, but so far you are choosing to follow-through with what they are asking. It takes a lot of strength to do that. Tell me what motivates you.”

45

ReframeReframe

This technique takes a client communication and gives it a different twist. It may be used to take negative client statement and give it a positive spin. An example:

Client: “I know that I made a mistake, but the hoops they are making me jump through are getting ridiculous.”

Counselor: “You are not happy about others having so much control, but so far you have been able to keep up with all their expectations and have been quite successful!”

46

Agreement with a twistAgreement with a twist

This is a complex technique that combines a reflection with a reframe. This gives the client confirmation that they were “heard” and then offers another perspective on their communication. It is similar to a reframe and an example is:

Client: “I know that I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”

Counselor: “You are feeling frustrated with all these expectations. You are also anxious to be successful with some things so you can keep moving forward.”

47

““Change-talk”Change-talk”

Opposite of Sustain-talkChange talk is client speech that favors

movement in the direction of change.

48

Examples of “Change-Talk”Examples of “Change-Talk”

“I really want to be a good daughter and I know I should make some changes.”

“I quit smoking when I decided I was ready and I think I can do this too.”

“I know I would be more motivated and do better in school if I cut down on my use.”

49

Techniques for eliciting “Change-Talk”Techniques for eliciting “Change-Talk”

Exploring problem Looking backward Looking forward Considering importance Exploring values and discrepancy with behavior Considering pros and cons (decisional balance) Importance/Confidence Ruler Exploring Extremes Planning and Committing

50

Exploring ProblemExploring Problem

Simply asking open-ended questions, reflecting and providing opportunity to explore the problem from the clients perspective. For example:

“Tell me a little more about…” “What do you think about …?” “Who influenced you…?”

51

Looking Forward/ Looking Looking Forward/ Looking BackwardBackward

Ask the client to look at what life was like prior to the current problem and explore it, in order to identify potential motivators. Also, look forward to goals and plans and explore how the current problem behavior “fits” with these goals. For example:

“What was life like for you before this became a problem?”

“Tell me how you see your life two or three years from now? How might this current problem effect these goals or plans?”

“What kinds of things did you used to do with your time? What things do you miss?”

52

Considering ImportanceConsidering Importance

Identify reasons that a change is important to the client. For example:

“You seem pretty committed to making a change. What motivates you?”

“I can see that you have been through a lot. Tell me in what ways making a change may help.”

53

Exploring Values and Discrepancy Exploring Values and Discrepancy with current behaviorwith current behavior

A conflict with values is often the strongest motivator for

change. Examples include:

“What is most important to you?” “How does your drinking effect the things in your life that

you value?” “When you look at your life, what are you most proud of,

least proud of?”

54

Considering Pros and ConsConsidering Pros and ConsDecisional BalanceDecisional Balance

Help the client to weigh the costs versus the benefits of the behavior in order to identify the ambivalence and move in the direction of positive change. Examples include:

“What are the good things about smoking pot and what are the not-so-good things?”

When you look at this list of pros and cons, what do you think?”

55

Importance/Confidence RulerImportance/Confidence RulerStudents are asked to choose a number between one and ten to

describe the level of importance they perceive about changing their behavior. They are also asked to place themselves on the scale in terms of the confidence they perceive in their ability to make that change. Examples of scaling questions include:

“On a scale of 1-10 with 10 being the most important and 1 being the least, how important is it for you to make this change?”

If the client chooses a 4, a follow-up question may be- “You chose a 4, tell me why you chose a 4 and not a 3 or a 2?” Asking the question in this way encourages “change” rather than “sustain” talk.

“On that same scale, how confident are you that you could make a change in this behavior if you decided to?”

56

Exploring ExtremesExploring Extremes

The counselor asks the client to consider what is the “worst thing” that could or may happen if he/she continues with current behavior pattern.

Counselor can also ask what is the best thing or things that could happen as a result of a behavior change.

57

Planning and Committing Planning and Committing

This includes talking with a client about how to make a change. Examples of questions include:

“If you were to decide to make a change, what steps might you take?”

“We have talked a lot about the reasons you think a change is important, Tell me how you will know that you are ready.”

58

Change-PlanChange-Plan

When the client has increased “change-talk” and there is little “sustain” talk this is a signal to the therapist that the client is ready to make a decision.

At this point, the therapist should shift to negotiating a change plan or strategy. This can be a formal exercise such as the change plan on the next slide or it can be a more informal conversation about the client’s options, desires, ideas about what might work.

59

Change Plan WorksheetChange Plan Worksheet The changes I want to make are: The most important reasons I want to change are: The steps I plan to take in making this change are: The ways other people can help me change are: Person Possible ways to help

Some things that could interfere with my plan are: I will know if my plan is working if:

______________________________Client Signature

______________________________Counselor Signature

(From the MET manual NIAAA clearinghouse Publication # 94-3723)

60

Motivational Interviewing Quiz!!Motivational Interviewing Quiz!!

What are the general principles of MI?:– Express __________– Develop __________– Roll with __________– Support __________– Avoid ____________

What are some techniques used in MI?

61

Sustain or Change Talk?Sustain or Change Talk?

“I really need to stop using or I think my girlfriend will break up with me.”

“My girlfriend thinks everyone has a problem because her father is an alcoholic.”

“I know I need to cut down, but I can do it on my own.”

“I feel ready to make this change and I know it will be difficult, but I have a good plan.

“Talking to you makes me feel worse. When can I go back to class?”

62

How can you incorporate MI into How can you incorporate MI into your practice? your practice?

Reflect on your current practice Clarify roles between MH and PC providers Develop protocols for incorporating MI into both

mental health and primary care practice; Create appointment times that accommodate

motivational interviews Get proper training (consult resources) Practice with your colleagues (see role play)

63

Motivational Interviewing in a Motivational Interviewing in a Brief Office Intervention Brief Office Intervention

64

The BNI-ART InstituteThe BNI-ART InstituteBrief Negotiated Interview and Brief Negotiated Interview and Active Referral to TreatmentActive Referral to Treatment

Boston, Massachusetts

Co-Directors: Edward Bernstein, MD; Judith Bernstein, RNC, PhD

65

Excellent Resource for SA MIExcellent Resource for SA MI

Brief Negotiated Interview and Active Referral to Treatment (BNI ART Institute)

http://www.ed.bmc.org/sbirt/– Information– Video clips– Printable handouts for students

The Brief Negotiation InterviewThe Brief Negotiation Interview

• establish rapport & ask permission to raise subject

• provide feedback about norms

• enhance motivation

• explore pros and cons

• assess readiness to change, resilience & assets,

discrepancies between actual state & goals

• develop action plan, using strengths/resources

1 2 3 4 5 6 7 8 9 10

67

The BNI for Adolescents:The BNI for Adolescents:

Using decisional balance Using decisional balance tools, CRAFFT, and tools, CRAFFT, and negotiating an action plannegotiating an action plan

video

68

ResourcesResources

http://www.motivationalinterview.org/clinical/One-stop shopResources for clinicians, researchers and

trainersprovide background information on the

practice of Motivational Interviewing, its applications to special populations

Non-English speaking materials

69

Resources cont.Resources cont.

Enhancing Motivation For Change in Substance Abuse Treatment (TIP 35)

Developed by William Miller, PhD and Steve Rollnick, PhD

First edition available free from www.samhsa.gov

Second edition Motivational Interviewing, Preparing People for Change

70

Resource for Substance AbuseResource for Substance Abuse

Brief Negotiated Interview and Active Referral to Treatment (BNI ART Institute)

http://www.ed.bmc.org/sbirt– Screening, brief intervention and referral to

treatment (SBIRT) toolkit– Instruction on BNI– Video clips– Printable handouts– Training opportunities– Technical assistance and consultation

71

Resource for ObesityResource for ObesitySchool Nurses, School-Based Health Centers and Childhood Overweight:

A report from a roundtable meeting to explore the role of school health professionals in preventing childhood overweight

www.healthinschools.org/Health-in-Schools/Health-Services/Schools-and-Childhood-Overweight/School-Nurses.aspx– Recommendations– Barriers– Sample programs

72

Contact InformationContact Information

Margaret Perlia Bavis, DNP, FNPMargaret Perlia Bavis, DNP, FNPInstructor, Community and Mental Health NursingInstructor, Community and Mental Health Nursing

Rush University College of NursingRush University College of Nursing   Margaret_A_Bavis@rush.edu

Sue Murray, MPH, RNSue Murray, MPH, RNProgram ConsultantProgram Consultant

Illinois Coalition of School Health CentersIllinois Coalition of School Health Centerssmurray@ilmaternal.orgsmurray@ilmaternal.org

73

Case Example and Role Play:Case Example and Role Play:Motivational Interviewing – ObesityMotivational Interviewing – Obesity

74

Obesity Case ExampleObesity Case Example Sarah is a 14 year old 9th grade student who has come

to the school-based health center for a comprehensive risk assessment. Sarah is obese and at risk for Type II Diabetes (family history). She has a history of overeating and reports that she does not engage in any physical activity. She gets short of breath when walking up stairs between classes, and feels embarrassed to go to a gym or to participate in group sports even though she would like to lose weight. Her family and friends often eat at fast food restaurants, and she usually goes with them and eats unhealthy meals. Sarah has tried to diet, but her diets have not lasted longer than about a week.

Practice a motivational interview with Sarah focused on improving her motivation to change behaviors associated with obesity – e.g., overeating, lack of activity, eating fast food.