using motivational interviewing to help your patients make behavioral changes 1

Using Motivational Interviewing to Help Your Patients Make

Behavioral Changes

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WHY SHOULD WE BE INTERESTED IN PATIENTS’ MOTIVATION FOR BEHAVIOR CHANGE?

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Beliefs About Motivation (True or False?)

1. Until a person is motivated to change, there is not much we can do.

2. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change.

3. Motivation is influenced by human connections.

4. Resistance to change arises from deep-seated defense mechanisms.

Beliefs About Motivation (True or False?)

5. People choose whether or not they will change.

6. Readiness for change involves a balancing of “pros” and “cons.”

7. Creating motivation for change usually requires confrontation.

8. Denial is not a client problem, it is a therapist skill problem.

Learning Objectives

At the end of the workshop, you will be able to:1. Define multiple MI techniques to help clients to change2. Describe the Stages of Change3. Complete a Stage of Change Assessment4. Define the 4 principles of MI5. Demonstrate skill with OARS6. Demonstrate at least 2 methods to elicit change talk7. Utilize a Readiness Ruler8. Complete a Decisional Balance9. Complete a Change Plan10. Describe MI strategies to deal with resistance to change

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MI is

• A theory• A set of skills • A way of thinking• A way of relating

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EXPERIENTIAL EXERCISE 1

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Why Do People Change?

1. ?2. ?3. ?4. ?5. ?6. ?

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Why Don’t People Change?

1. ?2. ?3. ?4. ?5. ?6. ?

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Sound Familiar?

• “I tell them what to do, but they won’t do it.”• “It’s my job just to give them the facts, and that’s all I

can do.”• “These people lead very difficult lives, and I

understand why they _______.”• “Some of my patients are in complete denial.”

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Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.

Or Should We?

• Explain what patients could do differently in the interest of their health?

• Advise and persuade them to change their behavior?• Warn them what will happen if they don’t change

their ways?• Take time to counsel them about how to change their

behavior?• Refer them to a specialist?

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Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.

The Righting Reflex:The Best Intentions Can Backfire

• Most patients are ambivalent about unhealthy behaviors.

• When we (providers) see an unhealthy/risky behavior, our natural instinct is to point it out & advise change.

• The patient’s natural response is to defend the opposite (no change) side of the ambivalence coin.

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Avoid Righting Reflex:“Taking Sides” Trap

PROVIDER• “You must change”• “You’ll be better off”• “You can do it!!”• “You’ll die…”

PATIENT• “I don’t want to

change”• “Things aren’t half bad.”• “No I can’t!!”• “Uncle Fred is 89 and

healthy as can be.”

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EXPERIENTIAL EXERCISE 2: THE CHANGE EXERCISE

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Exercise: The Change Exercise

• Stand up and turn to stand face to face in pairs. • Silently observe your partner for 15 seconds. • Now turn back to back

and change 3 things about yourself.

• When you are done, turn back to face your partner.

• Each person should take a minute to name the 3 things your partner has changed.

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Change Exercise Questions

• What was your comfort level during this exercise?• What made you comfortable or uncomfortable?• How hard was it to change things? • How did you decide what things to change about yourself?• What does this exercise tell us about change?• Look around you did you notice how quickly people changed

back to the way they started as soon as they sat down?• What implications might this have about change for people

and ourselves?

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Change Exercise Key Points

• Change is difficult• Change is not always comfortable• Change requires creativity• We tend to go back to old ways• It is easier to stay the same• We like our comfort zones• Change requires an open mind• Change has emotional and cognitive components

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Change Exercise Key Points

• Change is a process• Change happens over time• The process is as important as the result• Watch out for measuring success only if a change

occurred• Often there is a difference between what someone

knows they should do and there readiness to do it.• Greatest chance to impact change is pacing it to the

specific stage of change 18

Why Are Health Care Professionals (Outside Behavioral Health) Interested In MI?

• Behavioral/lifestyle factors in health issues– Exercise– Smoking– Weight control– Treatment adherence– Diet/nutrition

• Conceptual consistency with patient-centered approaches

• Positive and promising results from research on outcomes

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Definition of Motivational Interviewing

• A patient-centered, yet directive method for enhancing intrinsic motivation for positive behavior change by exploring and resolving ambivalence.”

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Miller, W.R. & Rollnick, S.(2002)

Motivation is viewed as…

• multidimensional • a state, which is dynamic and fluctuating• modifiable• influenced by communication style

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Our job is to elicit and reinforcepatient motivation for change.

Rapid Diffusion Into Health CareSettings…

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MOTIVATIONAL INTERVIEWING PRACTICE BASICS:

Spirit, Principles, Micro-skills

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MI Spirit

• A way of being with patients which is…– Collaborative– Evocative– Respectful of autonomy

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Collaboration(not confrontation)

• Developing a partnership in which the patient’s expertise, perspectives, and input is central to the consultation

• Fostering and encouraging power sharing in the interaction

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Evocation(not education)

• The resources and motivation for change reside within the patient

• Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals

• Ask key open ended questions

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Autonomy(not authority)

• Respecting the patient’s right to make informed choices facilitates change

• The patient is charge of his/her choices, and, thus, is responsible for the outcomes

• Emphasize patient control and choice

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Spirit of Motivational Interviewing

• Motivations to change are elicited from within the client, not imposed from outside.

• It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence.

• Direct persuasion is not an effective method for resolving ambivalence.

• Readiness to change is not a client trait, but fluctuating product of interpersonal interaction.

Spirit of Motivational Interviewing

• The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

• Positive atmosphere that is conducive but not coercive for change.

• The counselor is directive in helping the client to examine and resolve ambivalence.

What MI is Not

• A way of tricking people into doing what you want them to do• A specific technique• Problem solving or skill building• Just client-centered therapy• Easy to learn• A panacea for every clinical challenge

• Source: Miller & Rollnick (2009)

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Four Guiding MI Principles:

1. Resist the righting reflex• If a patient is ambivalent about change and

the clinician champions the side of change…

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Four Guiding MI Principles:

2. Understand your patient’s motivations• With limited consultation time, it is more

productive asking patients what or how they would make a change rather than telling them that they should.

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Four Guiding MI Principles:

3. Listen to your patient• When it comes to behavior change, the

answers most likely lie within the patient, and finding them requires some listening

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Four Guiding MI Principles:

4. Empower your patient• A patient who is active in the consultation,

thinking aloud about the what and how of change, is more likely to do something about it.

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Core MI Skills – (OARS)

• Asking• Listening• Affirming

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Asking

• Use of open ended questions allows the patient to convey more information

• Encourages engagement• Opens the door for exploration

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Closed Ended Question Open Ended Question

• Are you having any pain today?• Is there anything that is worrying you right now?• Are you short of breath?• Are you doing okay?• Why haven’t you tried this exercise?• Are you refusing treatment?• Do you have a follow up appointment scheduled?

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Open-Ended Questions

What are open-ended questions?

• Gather broad descriptive information• Require more of a response than a simple yes/no or

fill in the blank • Often start with words like:

– “How…” – “What…” – “Tell me about…”

• Usually go from general to specific

OARS

Open-Ended Questions

Exercise:Turning closed-ended questions into open-ended ones

Open-Ended Questions

• Why open-ended questions?– Avoid the question-answer trap

• Puts client in a passive role• No opportunity for client to explore ambivalence

OARS

Affirmations

What is an affirmation?

• Compliments, statements of appreciation and understanding– Praise positive behaviors– Support the person as they describe difficult

situations

OARS

Affirmations

• Examples:– “I appreciate how hard it must have been for you

to decide to come here. You took a big step.”– “I’ve enjoyed talking with you today, and getting

to know you a bit.”– “You seem to be a very giving person. You are

always helping your friends.”

Affirmations

Why affirm?• Supports and promotes self-efficacy, prevents

discouragement• Builds rapport• Reinforces open exploration (client talk)

Caveat:• Must be done sincerely

OARS

Express Empathy

What is empathy?• Reflects an accurate understanding

– Assume the person’s perspectives are understandable, comprehensible, and valid

– Seek to understand the person’s feelings and perspectives without judging

Express Empathy

Empathy is distinct from… • Agreement • Warmth• Approval or praise• Reassurance, sympathy, or consolation• Advocacy

Express Empathy

Why is empathy important in MI and IDDT?

• Communicates acceptance which facilitates change• Encourages a collaborative alliance which also

promotes change

• Leads to an understanding of each person’s unique perspective, feelings, and values which make up the material we need to facilitate change

Express Empathy

Tips…Good eye contactResponsive facial expressionBody orientationVerbal and non-verbal “encouragers”Reflective listening/asking clarifying questionsAvoid expressing doubt/passing judgment

Empathy is NOT…

• The sharing of common past experiences• Giving advice, making suggestions, or

providing solutions • Demonstrated through a flurry of questions• Demonstrated through self-disclosure

The Bottom Line on Empathy

• Ambivalence is normal • Our acceptance facilitates change• Skillful reflective listening is fundamental to

expressing empathy- Miller and Rollnick, 2002

Reflective Listening

OARS

Listening

• Clinician accurate empathy is a robust predictor of behavior change

• Involves careful listening with the goal of understanding the meaning of what the patient says

• Skillful reflective listening looks easy, but it’s a complex skill

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Reflective Listening

“Reflective listening is a way of checking rather than assuming that you know what is meant.”

(Miller and Rollnick, 2002)

OARS

Reflective Listening

• Why listen reflectively?– Demonstrates that you have accurately heard and

understood the client– Strengthens the empathic relationship– Encourages further exploration of problems and

feelings• Avoid the premature-focus trap

– Can be used strategically to facilitate change

Reflective Listening

In motivational interviewing,• About half of all practitioner responses are

reflections • 2-3 reflections are offered per question asked

In ordinary counseling, • Reflections constitute a small proportion of all

responses • Questions outnumber reflections 10 to 1

Learning Reflective Listening

• Reflective listening begins with thinking reflectively

• Thinking reflectively requires a continual awareness that what you think people mean may not be what they really mean

Thinking Reflectively

Exercise:1. Split up into triads (1-speaker) (2-listeners).2. Each person will take a turn being a speaker.3. Each person will share a personal statement

“One thing I like about myself is …”(e.g., I am organized. I am creative.)

4. The listeners respond with “Do you mean that…..” (generate at least 5 for each).

5. The speaker responds with only yes/no.

Reflective Listening

• A reflection is two things:– A hypothesis as to what the speaker

means– A statement

• Statements are less likely than questions to evoke resistance

OARS

Reflections Are Statements

“DO YOU MEAN……?”

• Use a statement to reflect your understanding

• Inflection turns down at the end“You...” “So you...”“Its...” “Its like...”“You feel...”

Reflections Are Statements

• Question:– You’re thinking about stopping? (inflection goes

up)

• Versus a statement:– You’re thinking about stopping. (inflection goes

down)

Reflective Listening

Exercise:1. Split up into triads (1-speaker) (2-listeners).2. Each person will take a turn being a speaker.3. Each person will share a personal statement

“One thing I like about myself is …”OR“One thing about myself I’d like to change is…”

4. The listeners respond with reflections only.5. The speaker can respond with yes/no and elaboration.

Levels of Reflection

• Simple Reflection – stays close– Repeating– Rephrasing (substitutes synonyms)

• Complex Reflection – makes a guess– Paraphrasing – major restatement, infers meaning,

“continuing the paragraph’– Reflection of feeling - deepest

OARS

Not Reflective Listening

Communication Roadblocks:1. Ordering, directing, commanding2. Warning, cautioning, threatening3. Giving advice, making suggestions, providing

solutions4. Persuading with logic, arguing, lecturing5. Telling what to do preaching6. Disagreeing, judging, criticizing, blaming

Not Reflective Listening

7. Agreeing, approving, praising8. Shaming, ridiculing, blaming9. Interpreting or analyzing, [also labeling]10. Reassuring, sympathizing, consoling11. Questioning, probing12. Withdrawing, distracting, humoring, changing

the subject

Summaries

• Pull together what has transpired thus far in a session

• Strategic use: practitioner selects what information should be included & what can be minimized or left out

• Additional information can also be incorporated into summary – e.g., past conversations, assessment results, collateral reports etc.

OARS

Summarizing

Exercise 3(part 1): 1. Choose a partner.2. Speaker: for 90 seconds talk about a habit,

behavior, situation you are thinking about changing.

3. Listener: listen only and then give a summary of what you’ve been told.

4. Change roles and repeat.

Summarizing

Exercise (part 2): 1. Change partners.2. Speaker: once again tell your story for 90

seconds w/out interruption.3. Listener: listen only and then give a

summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story.

4. Change roles and repeat.

Listen For Change Talk

DARNCAT Change•Desire: I want/wish/prefer to•Ability: I can, could, able, possible•Reason: why do it? what would be good?•Need: important, have to, matter, got to•Commitment: I will/am going to – signals behavior change•Activations: I am ready to do this•Taking Steps: I am taking steps

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Affirming

• Supports patient self-efficacy• Emphasize patient strengths• Notice and appreciate positive action• Genuineness is critical

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Affirmations May Include:

• Commenting positively on an attribute– (You are determined to get your health back.)

• A statement of appreciation– (I appreciate your efforts despite the discomfort

you’re in.)

• A compliment– (Thank you for all your hard work today.)

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Theoretical Framework ofMotivational Interviewing

“Readiness to Change”

1. Precontemplation – not yet considering change

2. Contemplation – evaluating reasons for and against change

3. Preparation – planning for change4. Action – making the identified change5. Maintenance – working to sustain changes70

EXPERIENTIAL EXERCISE 4: THE PERSUASION EXERCISE

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How Do We Assist Others to Change?

• Exercise has 2 parts:– Use Persuasion– Use Motivational Interviewing

• Reverse roles & answer same questions

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Let’s see if it works…Persuasion Exercise

• Ask your partner about a behavior that they have considered changing?

• Explain why participant should make a change• List at least 3 specific benefits of making this change• Tell the participant how to change• Emphasize how important it is for them to make the

change• Tell the person to do it!

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Exercise Part 3: Now Let’s TryUsing MI

1. Ask you partner to select a personal change they’ve have made in the past

2. What change did you make?3. How did you decide to make this change?4. What people or events influenced your

decision?5. What steps did you take to make the change?

6. What did you learn from the process?74

Exercise Part 3: Now Let’s TryUsing MI

7. Now, what’s a new change you’re considered now?8. What prompted you to look @ this issue now?9. How might you go about it in order to it, succeed?10.What are the 3 reasons to do it now?11.Summarize what you heard.12.Close by asking, what will you do next?

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PrecontemplationMaintenance

Action Preparation - Determination

ContemplationRelapse

Stages of Change

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CONCEPT DEFINITION APPLICATION

PRE-CONTEMPLATION Not consideringpossibility of change.Does not feel there is aProblem.

Goal: Raise awareness.Task: Inform and encourage.Validate lack of readiness.

CONTEMPLATION Thinking about change,in the near future.

Goal: Build motivation andConfidence.Task: Explore ambivalence.Evaluate pros and cons.

PREPARATION Making a plan to change,

setting gradual goals.

Goal: Negotiate a plan.Task: Facilitate decision making.

ACTION Implementation ofspecific action steps, behavioral changes.

Goal: Implement the plan.Task: Support self-efficacy.

MAINTENANCE Continuation of desirable

actions, or repeatingperiodic recommendedstep(s).

Goal: Maintain change or newstatus quo.Task: Identify strategies to

preventrelapse.

Stages of Change Model

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REMEMBER:“READINESS TO READINESS TO CHANGECHANGE” IS A STATE, NOT A TRAIT.

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READINESS RULERSA Precontemplation Stage Tool

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Readiness Rulers: I-C-R

• Importance: The willingness to change

• Confidence: In one’s ability to change

• Readiness: A matter of priorities

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Confidence

Readin

es

s

Imp

ort

an

ce

Importance Ruler

On a scale of 1 to 10, how important is it for you to make a change?

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1 2 3 4 5 6 7 8 9 10Not at all important

Somewhat important

ExtremelyImportant

Importance to Change Readiness Ruler

• We show the patient the Importance Readiness Ruler & ask: – On a scale of 1 to 10, how important is it to

you to make a change in . . . ? – Example, If you are a 5, why are you a 5 and

not a 3?– Or if you are a 5, what need to happen for you

to go to a 7?– How could I assist you in getting to a 7?

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Confidence Ruler

On a scale of 1 to 10, how confident are you that you could make a change if you wanted to?

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1 2 3 4 5 6 7 8 9 10Not at all confident

Somewhat confident

Extremelyconfident

Confidence to Change Readiness Ruler

• We show the patient the Confidence Readiness Ruler & ask: – On a scale of 1 to 10, how confident are you to

make a change in . . . ? – Example, If you are a 5, why are you a 5 and not a

3?– Or if you are a 5, what need to happen for you to

go to a 7?– How could I assist you in getting to a 7?

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Strategies to Enhance Confidence

• Review past successes• Define small steps that can lead to success• Problem solve to address barriers

– Hypothetical change (“If you were able to quit smoking tomorrow, how do you think things would be different?”)

• Attend to the progress and use slips as occasions to further problem-solve rather than failure

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Simplified Motivational Categories

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Importance of Change

Confidence in Ability Low High

Low

Group 1 – Little interest in change; don’t think they could even if they wanted to.

Group 2 – Want to change, but don’t think they are able.

High

Group 3 – Believe they could change, but not interested right now.

Group 4 – Want to change and believe they have the ability.

Readiness Ruler

On a scale of 1 to 10, how ready are you to make a change?

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

Somewhat ready

ExtremelyReady

Readiness to Change Readiness Ruler

• We show the patient the Readiness Ruler & ask: – On a scale of 1 to 10, how ready are you to make a

change in . . . ? – Example, If you are a 5, why are you a 5 and not a

3?– Or if you are a 5, what need to happen for you to

go to a 7?– How could I assist you in getting to a 7?

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Exercise 4: The Readiness Ruler Exercise

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Exercise 4:Let’s Try Using Readiness Rulers

• How important is it for you to learn about MI?• What are the challenges at your agency that

makes this MI training important ?• How confident are you that you can begin to

use utilizing what you’ve learned about MI in the next week?

• How ready are you to start utilizing what you’ve learned about MI in the next week

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Exercise 4: Utilizing Readiness Rulers

• You will be working with your partner in both the role of helper & helpee utilizing Readiness Rulers

• Start off by using the 3 questions from previous slide with your partner

• Then utilize importance, confidence & importance rulers

• Summarize outcome

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DECISIONAL BALANCEA Contemplation Stage Tool

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Decisional Balance:An Explanatory Model Of Behavior Change

• Highlights the individual’s ambivalence regarding maintaining vs changing a behavior

• it is a balancing of the costs of status quo with the costs of change

• and the benefits of change with the benefits of the status quo.

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Decisional Balance

Good things about behavior: Not so good things about behavior:

Not so good things about changing behavior: Good things about changing behavior

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Decisional Balance Worksheet(Fill in what you are considering changing)

Decisional Balance Sheet

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Good things about:1. 2. 3.

Not so good things about:1. 2. 3.

Not so good things about changing:1.2.3.

Good things about changing:1. 2.3.

Reasons for staying the same Reasons for making a change

Decisional Balancing—Benefits and Costs Worksheet

Continuing BehaviorCosts Benefits

1. 1.

2. 2.

3. 3.

4. 4.

Stopping BehaviorCosts Benefits

1. 1.

2. 2.

3. 3.

4. 4.

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Conducting a Decisional Balance Discussion

• Accept all answers. (Don’t argue with answers given by patient.)

• Explore answers.• Be sure to note both the benefits and costs of

current behavior and change.• Explore costs/benefits with respect to client’s

goals and values.• Review the costs and benefits.97

Exercise 5: The Decisional Balance Exercise

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Exercise 5: Decisional Balance

1. Partners will take turns as helper & helpee. 2. Helper begins by asking helpee to identify either:

a) “something I know I need to change & am considering” or

b) “something I feel 2 ways about”3. Helper assists helpee in completing a decisional balance4. Helper processes decisional balance with helpee using

OARS

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Exercise 5: Decisional Balance

1. Ask your partner to think of an area of their life in which they have been contemplating making a change.

2. For example:a) Starting a diet or exercise programb) Going back to schoolc) Moving to a new home.

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Negotiating a Change Plan

– Patient sets a goal– Have patient develop a menu of strategies—

brainstorm.– Have patient decide on a specific plan & summarize

it.– Elicit commitment

• Have patient restate what they intend to do.• Involve others: the more the patient verbalizes the plan

to others, the more commitment is strengthened (“no going back now” concept)

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Summary: Benefits of Using MI

• Evidence-based• Patient Centered• Provides structure to the consultation• Readily adaptable to health care settings

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What Do You Think?

1. On a scale of 1 to 10, how important is it for you to start using motivational interviewing in your practice?

2. On a scale of 1 to 10, how confident are you to start using motivational interviewing in your practice?

3. On a scale of 1 to 10,how ready are you to start using motivational interviewing in your practice?

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THANK YOU FOR COMING & LEARNING ABOUT MI!

ANY QUESTIONS?104

More Information on Motivational Interviewing

• Literature on MI: www.motivationalinterview.org• Miller and Rollnick. Motivational Interviewing:

Preparing People for Change. Guilford Press. New York and London. 2002

• Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press. New York and London. 2008

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Other Experiential Exercises

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Imagine Extremes

• “What is the worst that can happen if you continued?”

• What do you think would have to happen to make you decide to tell yourself, “ok that’s enough?”

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Looking Back

• “When was the last time things were going well for you and what was it like for you?”

• “What do you think could have prevented this setback?

• “What was your life like before this happened?”

• “As you step back and look at all this, what do you make of it?”

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Looking Forward

• “What would you like your life to be like in 2 years?”

• “How does what you are doing now make that difficult?”

• “What would it be like if you continue with the way things are now?”

• Suppose things don’t change, how do think your life will look?”

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Motivation for Change

• Motivation is an intrinsic process• Ambivalence

– Alternative behaviors have pluses and minuses

• Motivation arises out of discrepancy– Values/goals conflict with current behavior

• Ambivalence discrepancy change• “Change Talk” facilitates change

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Strengthening Commitment

• Summarize patient’s own perception of problem, ambivalence, desire/intention to change, and can include your own assessment.

• Ask a “key question”, i.e.: “What is the next step?”

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