05/12/2014

1

McKenzie Institute Mechanical Diagnosis and Therapy

Practitioners (MIMDTP) one day conference.

November 2014

The role of Motivational Interviewing in promoting behaviour

change

Dr Jeff Breckon PhD., C.Psychol., AFBPsS., SFHEA

Reader in Exercise Psychology

Themes

• Issues and myths of [PA] behaviour change

• Behaviour change counselling interventions

• Motivational interviewing

– Relational

– Technical

– Four processes

– Psycholinguistics of change (CT/ST)

• Where next?

05/12/2014

2

ISSUES OF [PA] BEHAVIOUR

CHANGE

ITS COMPLICATED!

4

www.employeewellnessnetwork.com

05/12/2014

3

“Over 75% of individuals do not maintain behavior

changes in multiple areas of behavior including

substance use, smoking, physical activity, nutrition, and

management of chronic physical and mental health

conditions”

(Naar-King, Earnshaw & Breckon, 2013)

PHYSICAL ACTIVITY (PA) specifically

• Multiple conditions (e.g. smoking, alcohol, diet)

• Requires significant effort

• It is a 'complex intervention'

• Success is dependant on environmental and social

factors as well as personal 'engagement‘

• ‘Positive contamination’

• Seasonality

05/12/2014

4

INFORMATION IS NOT ENOUGH:

ITS HOW YOU PRESENT INFORMATION THAT

MATTERS…

60%20%

BEHAVIOUR CHANGE COUNSELLING

INTERVENTIONS

The role of the health professional:

05/12/2014

5

Client outcomes before and after random

reassignment to a new counsellor

0

5

10

15

20

25

30

35

40

45

50

1 2 3 4

% Positive Urines

35

37

39

41

43

45

47

49

1 2 3 4

Methadone Use

30

35

40

45

50

55

60

1 2 3 4

% Employed

0

1

2

3

4

5

6

1 2 3 4

% Arrested

McLellan et al (1988) Journal of Nervous and Mental Disease, 176, 423-430.

Clinician effects

• Substantial empirical evidence indicates that clinicians account for a significant portion of outcome in behavioural and psychosocial treatments

• In fact, one of the best predictors for how well clients will do after behavioural interventions is which clinician they have

Moyers (2013)

05/12/2014

6

"We need to move beyond just a brand name"

(Terri Moyers)

MI

BAT

CBT

ACTIVE INGREDIENTS?

SFT

550 named behavioral therapies…

knowing the identification of core

components (that are part of many

successful interventions) is critical

(Fixsen, 2005)

MOTIVATIONAL INTERVIEWING

05/12/2014

7

A technical definition of MI

“Motivational interviewing is a collaborative, goal

orientated style of communication with particular

attention to the language of change. It is designed

to strengthen personal motivation for and

commitment to a specific goal by eliciting and

exploring the person’s own reasons for change

within an atmosphere of acceptance and

compassion.” (Miller & Rollnick, 2012)

A technical definition of MI

“Motivational interviewing is a collaborative, goal

orientated style of communication with particular

attention to the language of change. It is designed

to strengthen personal motivation for and

commitment to a specific goal by eliciting and

exploring the person’s own reasons for change

within an atmosphere of acceptance and

compassion.” (Miller & Rollnick, 2012)

05/12/2014

8

OR…

"MI with someone is like entering their home. One

should enter with respect, interest and kindness,

affirm what is good, and refrain from providing

unsolicited advice and rearranging their

furniture. “

(An Alaskan elder reflecting on an MI workshop by Steve Berg-Smith)

05/12/2014

9

MI

MI Spirit

Change

(and

Sustain)

Talk

MI Processes

MI Micro

skills

(OARS)

The Elements of Motivational Interviewing

Collaboration Acceptance

Compassion Evocation

MI Spirit

Adapted from Miller & Rollnick (2012)

MI

Spirit

05/12/2014

10

MI Micro skills

(OARS)

– Open ended questions

– Affirmations

– Reflective listening

– Summarising

OQs• Disadvantages of the Status Quo

• Advantages of Change• Optimism for Change• Intention to Change

1. What the client

means

2. Words the client

says

3. Words the practitioner hears

4. What the practitioner

thinks the client means

Four ‘+’ processesMI

Processes

05/12/2014

11

BENEFITS OF STAYING

THE SAME & COSTS OF

CHANGE

BENEFITS OF CHANGE &

COSTS OF STAYING THE

SAME

Sustain Talk

& (Discord)

Change TalkChange (and

Sustain) Talk

PREDICTOR

PRECURSOR

Sustain vs Change talk

• Desire

• Ability

• Reasons

• Need

• Commitment

• Activation

• Taking steps

05/12/2014

12

MI in physiotherapy and

rehabilitation?

• Lal & Korner-Bitensky (2013) Motivational

Interviewing: a novel intervention for translating

rehabilitation research into practice.

• Cheing et al (2014) Testing a path-analytic

mediation model of how motivational

enhancement physiotherapy improves physical

functioning in pain patients

• McGrane et al (2014) Addition of motivational

interventions to exercise and traditional

physiotherapy: a review and meta-analysis

WHERE NEXT?

05/12/2014

13

WHERE NEXT: VALUES MATCHING VS

STAGE MATCHING INTERVENTIONS(HUTCHISON, JOHNSTON & BRECKON, 2011)

Values card sort

1

6

2

7

34

1

09

8

5

1

61

5

1

4

1

3

1

2

1

1

1

91

8

1

7

20 21 22

05/12/2014

14

WHERE NEXT: IMPLEMENTATION

SCIENCE

SCIENCE TO SERVICE GAP

A key part of 'Implementation Science'

(Fixsen, 2010)

science service

SERVICE GAP

05/12/2014

15

The Challenge

• What is known is not what is adopted in the health sector

• What is adopted is not used with fidelity and good outcomes

for consumer

• What is used with fidelity is not sustained for a useful period

of time

• What is used with fidelity is not used on a scale sufficient to

impact on societal health problems

(Adapted from Fixsen, 2010)

WHERE NEXT: MI-CBT FOR

MAINTAINING BEHAVIOUR CHANGE

05/12/2014

16

CBT Maintenance Strategies and MI Integration (Naar-King, Earnshaw & Breckon, 2013)

Maintenance Strategy MI Integration

Managing the Goal Violation

Effect

• Avoid the term relapse

• Empathise with slips

• Elicit change talk about maintenance

• Consider an importance ruler

• Explore discrepancy between values/goals and slips Emphasise adoption of new behaviors

Flexible Goal Setting • Offer menu of options of short-term goals

• Develop a change plan’ for maintenance

• Consider a commitment ruler

Identifying Triggers and

Developing Coping Skills

• Ask for permission before engaging in treatment tasks

• Use Elicit-Provide-Elicit strategy when discussing rationales or providing information/advice

• Consider rulers for treatment tasks.

Supporting Self-Efficacy • Use affirmations instead of praise

• Ask open-ended questions to elicit confidence statements

• Consider an Affirmations Card Sort or a confidence ruler

• Avoid the ‘false-hope syndrome.’

Increasing Social Support • Use MI skills to increase motivation for social skills training or to address ambivalence about

engaging significant others

• Include specific plans for social support in the change plan for maintenance

• Consider addressing social support in each session in relation to specific treatment tasks.

Using Extrinsic Reinforcers • Use of MI skills to elicit the identification of internal reasons for maintenance

• Use Elicit-Provide-Elicit when discussing rationale

• Present reinforcers as a menu of options to support autonomy.

Information SourcesBreckon, J.D. (2014) Motivational Interviewing to promote physical activity and nutrition

behaviour change. In, Doing Exercise Psychology (M. Anderson & S. Hanrahan, Eds.). Human Kinetics, Champaign, Ill.

Breckon, J. D., Johnston, L. H. & Hutchison, A. (2008) Physical activity counseling content and competency: A systematic review. Journal of Physical Activity and Health, 5, 398-417.

Crust, L., Swann, C., Allen-Collinson, J., Breckon, J. & Weinberg, R. (2014) A phenomenological exploration of exercise mental toughness: Perceptions of exercise leaders and regular exercisers. Qualitative Research in Sport, Exercise and Health.

Hutchison, A., Breckon, J. D., & Johnston, L. H. (2009). Physical activity behaviour change interventions based on the transtheoretical model: A systematic review. Health Education & Behavior, 36, 829-845.

Johnston, L. H., Breckon, J. D. & Hutchison, A. (2008) Influencing Health Behaviour: Applying Theory to Practice. In, L. Dugdill, D. Crone and R. Murphy (Eds) Physical Activity and Health Promotion: Evidence-based Approaches to Practice. London: Blackwell

Miller, W.R & Rollnick, S. (2012) Motivational Interviewing: preparing people for change. London: Guilford Press.

Naar-King, S., Earnshaw, P. & Breckon, J. (2013) Towards a Universal Maintenance Intervention: Integrating Motivational Interviewing with Cognitive-Behavioural Strategies for Maintenance of Behaviour Change. Cognitive and Behavioral Practice, 27(2), pp.126-137.

Rollnick, S., Miller, W.R. & Butler, C. (2008) Motivational Interviewing in Health Care: Helping patients change behaviour. London: Guildford.

Rosengren, D. (2009) Building Motivational Interviewing Skills: A practitioner workbook. London: Guilford.

Scott, S., Breckon, J. & Copeland, R. (2014) Determinants and Strategies for Physical Activity Maintenance in Chronic Health Conditions: A Qualitative Study. Journal of Physical Activity and Health.

05/12/2014

17

Online MI training programme - For more information

go to emit.zembl.com

Dr. Jeff Breckon

j.breckon@shu.ac.uk

twitter: @jbreckon

THANKS FOR

LISTENING