Motivational InterviewingMotivational Interviewing

James L. Early, MDMedical Director – Via Christi Weight ManagementDirector of Clinical Preventive Medicine – KUSM-W

October 4, 2011

Objectives

• Participants will understand the definition of motivational interviewing and the basic elements of motivational interviewing.

• Participants will have an opportunity to consider where motivational interviewing may be of use to them.

• Participants will briefly practice some of the motivational interviewing skills.

Background

• Personal story– 40 years in medicine– Realization that more than biology and

chemistry are needed in medicine– Realization that people look for answers from

outside sources without fully exploring their own talents and resources and successes

– Hunger to help people make changes that positively impact their lives and their health

What is Motivational Interviewing?

Motivational Interviewing Stated in Another Way

Change

• We all struggle with change!

– Ambivalence about change is normal– Readiness to change is not static

Impo

rtan

ce

Confidence

Readiness

PrecontemplationPrecontemplation

ContemplationContemplation

PreparationPreparationActionAction

Relapse /Relapse / MaintenanceMaintenance

Prochaska’s Stages of Change

Elements of Motivational Interviewing

MI

The Spirit of Motivational Interviewing

• The 3 components of the MI spirit– Collaboration

• A partnership is established where it is recognized that the client is also an expert on themselves, their histories and their prior efforts at change.

– Evocation• The goal is to draw out from the clients their reasons

and potential methods for change and to offer ideas, as appropriate, for clients’ consideration.

– Autonomy• Never forget that the final decision making is left to the

client. They must eventually argue for their own change.

The Spirits Simple Truths

• Motivation for change predicts outcomes• It is an interpersonal process• It is responsive to simple acts of caring• It is responsive to brief empathic

counseling– Which sometimes is enough in itself!

Principles of Motivational Interviewing

• Rolling with resistance

• Express empathy

• Developing discrepancy

• Support self-efficacy

• R – Resist the righting reflex

• U – Understand your client’s motivation

• L – Listen to your client

• E – Empower your client

Foundational Skills - OARS

• Reflective listening• Open-ended questions• Affirmations• Summaries

How Will the Conversation Go?

• Paraphrase so they hear it twice or more if it is also later in the summary– What’s your opinion?– Pros and cons?– What do you like?– What role did the habit/behavior play in an

event?– Tell me more about:

• Health, wife, job, run-in with law/boss/friend

Eliciting Change Talk

Change Talk and Resistence

• Status quo is bad

• Change is worth it

• I am able to change

• I am going to do it!

• Status quo is OK

• Change wouldn’t be worth it

• It is too hard to change

• I’m not planning on doing it.

Opening a Session/Topic

• Even when you think you understand the basics of MI it can still be difficult to get the ball rolling.

• How do you start a conversation, keep resistance low, build trust and create a partnership; especially when the core of the issue is very sensitive or “itchy”?

Key Points in Starting a Conversation

• Begin with an attitude of real curiosity and a goal trying to understand more. (tobacco example)

• Match your strategies to the client’s readiness to change.

• Remember that being too confrontational may engender resistance!

• Remember too that you are not gathering evidence to support YOUR position…you are trying to allow the client to develop within themselves an argument for change that will work for them!

Stages of Change and Clinical Goals

Stage of Change Short-term clinical goals

Precontemplation Establish and build rapportRaise doubts about the “okayness” of alcohol/drug abuseIncrease awareness of discrepancy between goals or values and present behaviorKeep the door open

Contemplation Explore ambivalence in detailElicit and strengthen patient’s arguments in favor of changeExplore action hypothetically

Preparation Clarify patient’s goals for changeExplore change options (e.g. more intensive treatment)

Action Maintain change using reinforcement of new behaviors and adherence to change planSupport patient’s relapse prevention plan

Maintenance Explore and try out new lifestyle elements

Chris Dunn, PhD- personal communicationUniversity of Washington, 2011

Strategies for Opening a Session

• Set an agenda and gently set a basic outline of the time and critical issues to be covered while allowing maximal leeway for the client to initially express his/her major concern.

• A typical day is a strategy that may allow the behavior in question to arise naturally as the day is thought through. The timeline of the day may allow an opening to gently probe without seeming pushy or asking directly about “the problem”.

Strategies for Opening a Session

• Normalizing the behavior can be an opportunity to make it clear that you are not shocked or judgmental when the client brings up a topic. Unless the “problem” is a serious and dangerous crime your primary job is to allow the client to see the issue clearly and begin to consider change.

• Offering a concern is also reasonable but needs to be accompanied by any supportive statements from the client. It is critical that the client’s view and autonomy are generously included in your concern.

Exercises

Exercise #1

• The use of the “favorite teacher or motivator”– Name– Overall characteristics– What about them or their

actions/personalities inspired you to do or to be your best?

– How did you initially and later respond to their efforts?

Examples of Issues

Abusive spouse – leave or stayProblem drinking – quit/cut back/not a problemSmoking – quit/cut back/not a problemExercise – start/increase/exclude the possibilityDiet – modify calories/modify quality and content/don’t addressDiabetes – better control/resolve/accept current level and prevent worseningObesity – accept as is/lose weight/lose weight only indirectly

Exercise #2 (a)

• Client (Sarah’s husband): I’m just furious that she lied to me and had this affair behind by back. I can’t believe I didn’t see it. I feel like such an idiot.

• Practitioner: In retrospect, what signs did you overlook?

Thumbs UP___ Thumbs DOWN____

Thoughts About (a)

• Thumbs down. • This is an instance where evocation and

collaboration might take the practitioner in different directions. The practitioner might be better served by paying attention to the supportive aspects of collaboration first. More specifically, the practitioner missed the chance to express empathy and instead slipped into information gathering.

Exercise 2 (b)

• Client (Arthur): I know my dad told you I’m depressed, but I’m not. Just because I don’t want to play football doesn’t mean I’m depressed.

• Practitioner: Your father is worrying needlessly. What do you think he’s seeing that makes him worry this way?Thumbs UP________ Thumbs DOWN _____

Thoughts About (b)

• Thumbs up. • Again we see collaboration and evocation

present, but this time the practitioner attends to the relationship issues first. The practitioner offers a reflection, followed by an open-ended question that encourages exploration in the direction of change.

Exercise 2 (c)

• Client (Sarah): I’ve had it with Richard's guilt mongering. Okay, so I had an affair. I’m ready to end it and start working on our marriage, but I don’t think he’s ever going to let me forget it. Maybe we should just get a divorce.

• Practitioner: Sarah, you are the only one who can decide if you should stay in this marriage or leave it. I wonder what signs you would need to feel more optimistic about working on this with Richard?

Thumbs UP __________ Thumbs DOWN __________

Thoughts About (c)

• Thumbs UP. • The practitioner has acknowledged

Sarah’s autonomy in making the decision about her marriage, but has also shifted the conversation toward self-exploration and optimism.

Let’s Walk Through the Process

• Checking you motivation• Where to begin?• Stages of readiness• Express empathy and form collaboration• Listen (reflectively)(open-ended questions/affirm/summarize)• Figure out where the client is coming from and the conflict it

represents• Evoke reasons and potential methods for change (client’s past)• Roll with resistance!• Empower (affirmations from conversation to that point) and

support self-efficacy (support autonomy)• Elicit change talk• Seal the deal, but only when ready!

“It is not time that changes man, nor knowledge; the only thing that can change someone’s mind is love.”

Paul Coelho eleven minutes

Break

Let’s Do It

• Agree to discuss topic– make it clear that you won’t and can’t change them– “I know it is a heavy/difficult topic but can we go

there?”• Explore importance and confidence

– 1-10 for both– What would make the importance/confidence

more or less?• Discuss action

– Implementation Intention Intervention• Who, what, when and where

• Close on good terms– Affirmation and summary

Examples of Issues

Abusive spouse – leave or stayProblem drinking – quit/cut back/not a problemSmoking – quit/cut back/not a problemExercise – start/increase/exclude the possibilityDiet – modify calories/modify quality and content/don’t addressDiabetes – better control/resolve/accept current level and prevent worseningObesity – accept as is/lose weight/lose weight only indirectly

References