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Effecting Change through the use of
Motivational Interviewing
ISAP/UCLA Psychiatrist TrainingApril 6, 2009
Jeanne L. Obert, MFT, MSM
Executive Director, Matrix Institute
UCLA Integrated Substance Abuse Programs
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Motivational Interviewing,
2nd Edition. Miller and Rollnick
We can’t help wondering, why don’t people change? You would think:
• that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication
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You would think…..
• that the very real threats of blindness, amputations and other complications from diabetes would be enough to motivate weight loss and glycemic control
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You would think…..
• that time spent in the dehumanizing privations of prison would dissuade people from re-offending
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You would think…..
• that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a person to stop
drinking
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AND YET
• Addictive behaviors persist despite overwhelming evidence of their destructiveness.
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What has occurred
The field of addictions has provided a natural arena to study the process of change.
• What causes change to occur?• How does the process unfold?• Is it possible to “push the river”?• What is the best way to do that?
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A patient-centered directive method for enhancing intrinsic motivation to change by
exploring and resolving ambivalence.
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Stages of ChangeProchaska & DiClemente
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Precontemplation Stage
• Definition
Not yet considering change or is unwilling or unable to change
• Primary task
Raising Awareness
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Some Ways to Raise Awareness in the Precontemplation Stage
• Offer factual information
• Explore the meaning of events that brought the person in and the results of previous efforts
• Explore pros and cons of targeted behaviors
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Contemplation Stage
• In this stage the patient sees the possibility of change but is ambivalent and uncertain about beginning the process
• Primary task
Resolving ambivalence and helping the patient choose to make the change
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Possible Ways to Help in the Contemplation Stage
• Talk about the person’s sense of self-efficacy and expectations regarding what the change will entail
• Summarize self-motivational (change talk) statements
• Continue exploration of pros and cons
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Determination Stage
• In this stage the patient is committed to changing but is still considering exactly what to do and how to do
• Primary task
Help patient identify appropriate change strategies
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Possible Ways to Help in the Determination Stage
• Offer a menu of options for change or treatment
• Help patient identify pros and cons of various treatment or change options
• Identify and lower barriers to change• Help person enlist social support • Encourage person to publicly announce
plans to change
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Action Stage
• In this stage the patient is taking steps toward change but hasn’t stabilized in the process
• Primary task
Help implement the change strategies and learn to limit or eliminate potential relapses
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Possible Ways to Help in the Action Stage
• Support a realistic view of change through small steps
• Help person identify high-risk situations and develop appropriate coping strategies
• Assist person in finding new reinforcers of positive change
• Help access family and social support
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Maintenance Stage
• Definition
A stage in which the patient has achieved the goals and is working to maintain them
• Primary task
Patient needs to develop new skills for maintaining recovery
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Possible Ways to Help in the Maintenance Stage
• Help patient identify and try alternative behaviors (drug-free sources of pleasure)
• Maintain supportive contact • Encourage person to develop escape plan• Work to set new short and long term goals
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Recurrence
• Definition
Patient has experienced a recurrence of the symptoms
• Primary task
Must cope with the consequences and determine what to do next
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How to Help the Patient Who Has Experienced a Recurrence
• Explore with person the meaning and reality of recurrence as a learning opportunity
• Explain Stages of Change and encourage him/her to stay in the process
• Help person find alternative coping strategies• Maintain supportive contact
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How Can I Help Patients Move through These Stages of Change?
• Use the microskills • Open-ended questions• Affirmations• Reflections• Summaries
• to elicit and reinforce change talk
• while observing the principles of MI
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Four Principles ofMotivational Interviewing
1. Express empathy
2. Develop discrepancy
3. Avoid argumentation
4. Support self-efficacy
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1. Express Empathy
•Acceptance facilitates change
•Skillful reflective listening is fundamental
•Ambivalence is normal
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2. Develop Discrepancy
•Discrepancy between present behaviors and
important goals or values motivates change
•Awareness of consequences is important
•Goal is to have the PERSON present reasons
for change
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3. Avoid Argumentation
•Resistance is signal to change strategies
•Labeling is unnecessary
•Shift perceptions
•Peoples’ attitudes shaped by their words,
not yours
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4. Support Self-Efficacy
• Belief that change is possible is important motivator
• Person is responsible for choosing and carrying out actions to change
• There is hope in the range of alternative approaches available
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Building MotivationOARS
•Open-ended questioning
•Affirming
•Reflective listening
•Summarizing
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Open-ended Questions
• An open-ended question is one with more than a yes or no response
• Helps person elaborate own view of the problem and brainstorm possible solutions
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Affirmations
• Focused on achievements of individual
• Intended to:– Support person’s persistence– Encourage continued efforts– Assist person in seeing positives– Support individual’s proven strengths
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Reflective Listening Key-concepts
• Listen to both what the person says and to what the person means
• Check out assumptions• Create an environment of empathy
(nonjudgmental)• You do not have to agree• Be aware of intonation (statement, not
question)
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SUMMARIZING
Summaries capture both sides of the ambivalence
(You say that ___________ but you also mentioned that ________________.)
Summaries also prompt clarification and further elaboration from the person.
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Change Talk
•Recognizing the problem
•Expressing concern
•Stating intention to change
•Being optimistic about change
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Signs of Readiness to Change
•Less resistance
•Fewer questions about the problems
•More questions about change
•Self-motivational statements
•Resolve
•Looking ahead
•Experimenting with change
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[email protected] [email protected]
www.matrixinstitute.orgwww.matrixinstitute.orgwww. uclaisap.orgwww. uclaisap.org
http://motivationalinterview.org
Enhancing Motivation for Change in Enhancing Motivation for Change in Substance Abuse TreatmentSubstance Abuse Treatment
TIP 35TIP 35
[email protected] [email protected]
www.matrixinstitute.orgwww.matrixinstitute.orgwww. uclaisap.orgwww. uclaisap.org
http://motivationalinterview.org
Enhancing Motivation for Change in Enhancing Motivation for Change in Substance Abuse TreatmentSubstance Abuse Treatment
TIP 35TIP 35