Taste of Motivational InterviewingCharles H. Bombardier, PhDDepartment of Rehabilitation MedicineUniversity of Washington School of MedicineSeattle Washington USAAustralian Psychological Society's Rehabilitation Psychology Interest Group 2010

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“Taste” of Motivational Interviewing

Taste not training (training is usually 2-3 days) Reasons to consider learning MI Stages of Change/Readiness to change Empirical and theoretical basis for MI Describe motivational interviewing strategies Provide opportunities to practice selected

motivational interviewing strategies

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Ground Rules and Expectations

There’s no magic bullet I am not here to change

your overall approach to handling clients

Some strategies may fit your style, others may not

Take what you can use and leave the rest

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Give it to me straight doc. How long do I have to ignore your advice?

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Helpful Responses QuestionnaireWhat is the first thing you want to say in response to

clients who make these statements?1. (Meets criteria for MDD) ―I’m not depressed.‖

2. ―Those exercises are making my pain worse.‖

3. ―Why do I have to do the [exposure activities]?‖

4. ―I forgot to do my homework.‖5. ―You don’t understand what it is like to have X.‖

6. ―I want to change my drinking on my own.‖

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Contrasting Communication Styles

MI Style Patient-oriented Collaborative Focus on motivation Explore ambivalence Elicit reasons to change Elicit concerns Clinician listens more

Traditional Fixer Style Goal-oriented Expert role Focus on action Direct persuasion Give reasons to change Give warnings Clinician talks more

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What is Motivational Interviewing?

Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence

www.motivationalinterview.org

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Motivational Interviewing

Collaboration Evocation Autonomy

Spirit

ExpressEmpathy

DevelopDiscrepancy

Roll withResistance

SupportSelf-efficacy

Principles

Open-endedQuestions

ReflectiveListening Affirm Summarize Elicit

Change Talk

Key Strategies

Miller and Rollnick, 2002

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Less like this…

More like this

WHY BOTHER LEARNING MOTIVATIONAL INTERVIEWING?

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The Problem of Non-adherence

Simply giving patients advice to take medications or make lifestyle changes is often not effective.

Rates of Nonadherence Anti-hypertension drugs: 50% Physical therapy: 33%-66% Sluijs, 1993

Home exercise program: 36% never do Forkan, 2006

Antibiotics: 27% (qd), 48% (tid), 58% (qid) Rule of one-third

(Meichenbaum & Turk, 1987)

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Stages of Change Heuristic

Precontemplation-not considering change; reluctant, resigned, resistant, unaware

Contemplation-normal ambivalence about change, both pros and cons of change are present within the person

Determination-getting ready to change Action-overt change begins Maintenance-sustaining change for >6 months Relapse-normal resumption of pre-change

behavior (5-8 relapses are common)

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Stages of Change for Selected Health Behaviors

Behavior PreCon Contemp Action Mainten

Quit Smoking 15% 27% 20% 37%

Weight Control 14% 53% 18% 15%

Low Fat Diet 23% 18% 3% 57%

Sunscreen Use 52% 8% 4% 35%

Start Exercising* 7% 34% 14% 19%

*25% were in Determination

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Determinants of Patient Adherence

Meichenbaum and Turk, 1987

Treatment

Symptoms

Organization

Patient

Relationship

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Resistance is Interpersonal

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Determinants of Resistance

Personality differences play a minor role in resistance/motivation

Resistance/Motivation is interpersonal. Confrontation increases resistance and

predicts poor outcome one year later Empathic listening decreases resistance

Reducing resistance is the health care professional’s responsibility

Motivational Interviewing is Theoretically Sound

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Inhibitors of Change Patterson-therapist teaching and confronting

increase observable client resistant behaviors in therapy sessions.

Therefore, we avoid confronting clients with information or giving unsolicited advice. We ask for permission before giving advice. We reflect rather than confront resistive statements.

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Facilitators of Change Rogers-Accurate empathy promotes change.

Therefore, we use reflective listening to demonstrate understanding and acceptance of the client’s subjective situation

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Facilitators of Change Rokeach-Awareness of a discrepancy between

behavior and core values creates change

Therefore, we elicit the person’s core values or goals and then clarify how their behavior fits or does not fit with these important ideas.

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Facilitators of Change

―People are generally better persuaded by the reasons which they themselves discovered, than by those which have come into the mind of others.‖

Paschal’s Pensees (17th century)

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Facilitators of Change Bem/Self Perception Theory: As I hear myself talk, I

learn what I believe. Festinger/Cognitive Dissonance Theory: If I say it

and no one has forced me to say, I must believe it.

Therefore, we use reflections and open-ended questions to elicit from the person ―change talk‖ i.e. reasons to change, intent to change, commitment to change……AND

Avoid the reverse….eliciting resistive statements

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Facilitators of Change Sanchez-Craig - Choice enhances adherence. Brehm/Theory of Reactance - Threats to

freedom elicit resistance.

Therefore, we try to give the client choices and explicitly emphasize their autonomy and right to choose or even refuse.

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Facilitators of Change Bandura/Self-efficacy Theory: Optimism and

hope facilitate change.

Therefore, we try to reinforce successive approximations to the goal. We affirm the person, point out their successes, even small ones. We reframe ―failures‖ as intermediate successes whenever possible.

Motivational Interviewing is Evidence-Based

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Efficacy of MI: Randomized Controlled Trials

Alcohol abuse N=13; ES 0.26 (0.18-0.33) reduced drinking and re-injury (Gentilello et al., 1999)

lower frequency and problems (Marlatt et al., 1998)

fewer drinks and drinking days (Miller et al., 1993)

less risky driving (Monti et al., 1999)

Drug use N=13; ES 0.29 (0.15, 0.43)

Smoking cessation N=14; ES 0.14 (0.09, 0.20)

Hettema, Steele, Miller Ann Rev Clin Psychol 2005

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Efficacy of MI: Randomized Controlled Trials

HIV risk reduction 5 studies ES 0.53 (0.24, 0.81)

Diet and exercise N=4; ES 0.78 (0.41-1.16) increased physical activity (Harlan, 1999)

better treatment adherence (Smith, 1997)

Treatment compliance N=5; ES 0.72 (0.56, 0.89)

Hettema, Steele, Miller Ann Rev Clin Psychol 2005

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Conclusions from Meta-analysis

72 clinical trials; average dose 2.24 hours Average short-term between group ES = 0.77;

long term ES=0.30 Effect sizes were larger with ethnic minorities

and when treatment was not manual guided Trends toward larger more durable effects

when MI was added at the outset of another treatment program

Hettema, Steele, Miller Ann Rev Clin Psychol 2005

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Interim Summary

Nonadherence to professional advice is poor People are not always ready to change Resistance to change is the clinician’s

responsibility Motivational interviewing has a strong

theoretical and empirical basis A wide variety of professionals can to learn MI

to add to their communication skills

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Indications and Contraindications for Motivational Interviewing

The person is ready to change/accept advice—no need for motivational interviewing They ask for advice They spontaneously voice commitment language: ―I will do that..‖ ‖I am going to do that…‖

The person is ambivalent or resistant-motivational interviewing works better than UC ―I could, should, would like to…do that‖

―Yes, but…‖

―I have tried that before…‖

―There’s no way I can…‖

Trying Out Selected Motivational Interviewing

Strategies

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Recognizing Resistance

Verbal Arguing Interrupting Denying Disagreeing Minimizing Pessimism Sidetracking

(Miller & Rollnick, 1991)

Non-Verbal Poor eye contact Arms/legs crossed Turned away Volume Facial/body tension Clenched jaw/fists Slouched posture

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Recognizing Contemplation

Ambivalence about changing Yes…..but, I’m not sure…

Half-hearted commitment I’ll try to … I wish I could…

Giving in If you say so…

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Listening for Stage of Change

1. (Meets criteria for MDD) ―I’m not depressed.‖

2. ―Those exercises are making my pain worse.‖

3. ―Why do I have to do the [exposure activities]?‖

4. ―I forgot to do my homework.‖

5. ―You don’t understand what it is like to have X.‖

6. ―I want to change my drinking on my own.‖

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MI Acronym-OARSOpen-ended questions Affirmations Reflections Summaries

Communicating is to MI

asStepping is to Dancing

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Open Questions

Open questions are ones that cannot be answered with a ―yes’ or ―no‖

Open questions gets the client talking, hopefully about change

Using open questions you can demonstrate empathy and acceptance, elicit ―change talk‖, develop discrepancy, etc.

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Practice Open-ended Questions

Look at practice sheet (next slide) Try to come up with more than one open

ended question that would help get the conversation going in a positive direction.

Initial goals might be to communicate: Acceptance Non-judgmental attitude Not going to control them Elicit values Maybe ―Good things, not so good things‖

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Practice Open Ended Questions

1. (Meets criteria for MDD) ―I’m not depressed.‖

2. ―Those exercises are making my pain worse.‖

3. ―Why do I have to do the [exposure activities]?‖

4. ―I forgot to do my homework.‖5. ―You don’t understand what it is like to have X.‖

6. ―I want to change my drinking on my own.‖

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Tips on Reflective Listening

Guess at what they mean. Make a statement not a question. With

questions inflection goes up at the end. With statements, inflection stays down at the end. ―So, you think…‖

―Your are wondering if…‖

―It sounds like …‖

Repeat an element (short summary) Paraphrase with synonyms Reflect a feeling

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Reflective Listening

Demonstrates your understanding Demonstrates empathy, acceptance Mirrors back to the person elements of what

they are saying that they may not be aware of Facilitates their self-understanding, insight Decreases resistance

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Simple Reflections-Batting Practice

I will throw out some statements Attempt to simply reflect the content of the

statement Don’t worry about not being perfect, just try to

get some ―wood‖ on the ball. Next, let’s attempt to reflect the feeling behind

the statement.

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Practice Reflections1. (Meets criteria for MDD) ―I’m not depressed.‖

2. ―Those exercises are making my pain worse.‖

3. ―Why do I have to do the [exposure activities]?‖

4. ―I forgot to do my homework.‖

5. ―You don’t understand what it is like to have X.‖

6. ―I want to change my drinking on my own.‖

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Types of Reflective Listening

Simple reflection – demonstrate empathy, highlight change talk ―Exercise does not seem that useful to you.‖

Double-sided reflections - used to reflect both sides of ambivalence toward change ―Your doctor wants you to exercise but you are not

interested.‖

Amplified reflections - often used to reflect resistive statements ―You think exercise would be a waste of your time.‖

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Practice Reflections II

1. (Meets criteria for MDD) ―I’m not depressed.‖

2. ―Those exercises are making my pain worse.‖

3. ―Why do I have to do the [exposure activities]?‖

4. ―I forgot to do my homework.‖

5. ―You don’t understand what it is like to have X.‖

6. ―I want to change my drinking on my own.‖

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Affirming

Elicit their strengths and successes Reinforce some strength or small success If they attained part of a goal, focus on what

part they accomplished not the part left undone Reframe failure as a partial success or

something they can learn from Set goals that have a high likelihood of

success Try affirming Helpful Responses statements

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Find Something to Affirm1. (Meets criteria for MDD) ―I’m not depressed.‖

2. ―Those exercises are making my pain worse.‖

3. ―Why do I have to do the [exposure activities]?‖

4. ―I forgot to do my homework.‖

5. ―You don’t understand what it is like to have X.‖

6. ―I want to change my drinking on my own.‖

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Motivational Interviewing

Collaboration Evocation Autonomy

Spirit

ExpressEmpathy

DevelopDiscrepancy

Roll withResistance

SupportSelf-efficacy

Principles

Open-endedQuestions

ReflectiveListening Affirm Summarize Elicit

Change Talk

Key Strategies

Miller and Rollnick, 2002

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Values and Goals

What keeps you going through all this? What keeps you motivated? When you think of your whole life, what matters

most to you? Or use values checklist And…where do all these exercises fit in with

that?

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Values Checklist

Good parent Good spouse/partner Competent Healthy Attractive Energetic Responsible Youthful Athletic Spiritual

Considerate Disciplined Respected at work Efficient Independent Good role model In control Strong Popular Faithful Other ______________

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Eliciting Change Talk - Content

DARN Desire to change Ability to change Reasons to change Need to changeCommitment to Change ―I will do that‖ ―I intend to ..‖ ―I am going to…‖

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Predictors of Behavior Change

Desire Ability Reasons Need

Commitment Language

Behavior Change

Amrhein, Miller, Yahane JCCP, 2003

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Eliciting Change TalkExample: I’ve got good days and bad days Disadvantages of the status quo-What concerns

being so up and down? Advantages of change-How would your life be

better if you were more stable? Optimism about change-What makes you think

you could become more stable if you wanted to? Intention to change-What strategies would you

be willing to try to dampen the ups and downs?

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Summarize

Collecting summary-reinforces (elements of) what has been said, lets them know you are following Reflect, reflect, what else? Summarize

Linking summary-ties together what the person has just said with earlier material, usually to help them reflect upon ambivalence On one hand you feel x, y, z and on the other hand

you also feel a, b, c. Transitional summary-wrap up the end of a

session or move on to another topic

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Facilitating Choice: Menu of Options

Doing moreenjoyableactivities

Doingproblem-solving

Somethingelse?

Changingnegativethinking

“When we work with people who struggle with depression a variety of strategies can help. Which strategy seems like it would be most helpful for you?”

Increasingphysicalactivity

Considerantidepressant

meds

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Good things, less good things Ask about the good things about the ―bad‖

behavior first Why? Reflect, reflect, summarize

Ask about the not so good things about the ―bad‖ behavior Reflect, reflect, summarize

Summarize both sides Ask key question: Where does this leave you

now

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Giving Advice: Elicit-Provide-Elicit

Elicit what they already know and think Provide information

Ask for permission to give information Use neutral, non-personal language ―What other people in your situation have done …‖

Be a little reluctant ―You’re the expert about your life, but if you want I’ll offer some ideas.‖

Offer at least two potential options Elicit their reaction ―Now I wonder what you

make of all this?‖

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Brief MI: Importance

How important is it right now for you to …? On a scale from 0 to 10 what number would you give yourself?

Why are you at X and not at 1? What would need to happen for you to get from

X to (slightly higher number)?Rollnick, 1999

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Brief MI: Confidence

If you decided to change, how confident are you that you would succeed? On a scale from 0 to 10 what number would you give yourself?

Why are you at X and not at 1? What would need to happen for you to get from

X to (slightly higher number)?Rollnick, 1999

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Process of MI

Open-ended questions-Elicit change talk:

• Desire, Ability, Reasons, Need• Good things, not so good things…• Decisional balance exercise• Importance-Confidence exercise• Values/Discrepancy

Reflections and

Affirmations

Summaries

Key Question

NegotiateChange Plan

Empathy, Autonomy, Collaboration, Self-Efficacy

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Wrap-Up What, if anything, do you want to do to begin

integrating motivational interviewing tools into how you interact with patients? Listen for client readiness, resistance Notice what happens when I give unsolicited advice Try asking more open ended questions and notice

what happens Try listening and reflecting more and see what

happens Sign up for a two-day course on MI

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Key Resources

Miller W. & Rollnick, S. (1991, 2002) Motivational Interviewing: Preparing People for Change. Guilford Press: New York.

Rollnick, S., Miller, W. & Butler, C. (2008). Motivational Interviewing In Health Care. Guilford Press: New York.

www.motivationalinterview.org Questions? chb@u.washington.edu

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More Readings

Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003;71:843-861.

Hettema J, Steele J, Miller WR. Motivational interviewing. Ann Rev Clin Psychol 2005;1:91-111.

Miller, WR. Rediscovering fire: Small interventions, large effects. Psychol Addict Behav 2000;14:6-18