Title: Using Motivational Interviewing to Help Your Patients Make Behavioral Changes
1Using Motivational Interviewing to Help Your
Patients Make Behavioral Changes
2Why Should We Be Interested In Patients
Motivation For Behavior Change?
3Beliefs About Motivation (True or False?)
- Until a person is motivated to change, there is
not much we can do. - It usually takes a significant crisis (hitting
bottom) to motivate a person to change. - Motivation is influenced by human connections.
- Resistance to change arises from deep-seated
defense mechanisms.
4Beliefs About Motivation (True or False?)
- People choose whether or not they will change.
- Readiness for change involves a balancing of
pros and cons. - Creating motivation for change usually requires
confrontation. - Denial is not a client problem, it is a therapist
skill problem.
5Learning Objectives
- At the end of the workshop, you will be able to
- Define multiple MI techniques to help clients to
change - Describe the Stages of Change
- Complete a Stage of Change Assessment
- Define the 4 principles of MI
- Demonstrate skill with OARS
- Demonstrate at least 2 methods to elicit change
talk - Utilize a Readiness Ruler
- Complete a Decisional Balance
- Complete a Change Plan
- Describe MI strategies to deal with resistance to
change
6MI is
- A theory
- A set of skills
- A way of thinking
- A way of relating
7Experiential Exercise 1
8Why Do People Change?
- ?
- ?
- ?
- ?
- ?
- ?
9Why Dont People Change?
- ?
- ?
- ?
- ?
- ?
- ?
10Sound Familiar?
- I tell them what to do, but they wont do it.
- Its my job just to give them the facts, and
thats all I can do. - These people lead very difficult lives, and I
understand why they _______. - Some of my patients are in complete denial.
Rollnick, Miller and Butler. Motivational
Interviewing in Healthcare. 2008.
11Or 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 dont change
their ways? - Take time to counsel them about how to change
their behavior? - Refer them to a specialist?
Rollnick, Miller and Butler. Motivational
Interviewing in Healthcare. 2008.
12The Righting ReflexThe 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 patients natural response is to defend the
opposite (no change) side of the ambivalence
coin.
13Avoid Righting ReflexTaking Sides Trap
- PROVIDER
- You must change
- Youll be better off
- You can do it!!
- Youll die
- PATIENT
- I dont want to change
- Things arent half bad.
- No I cant!!
- Uncle Fred is 89 and healthy as can be.
14Experiential Exercise 2 The Change Exercise
15Exercise 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.
16Change 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?
17Change 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
18Change 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
19Why 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
20Definition of Motivational Interviewing
- A patient-centered, yet directive method for
enhancing intrinsic motivation for positive
behavior change by exploring and resolving
ambivalence.
Miller, W.R. Rollnick, S.(2002)
21Motivation is viewed as
- multidimensional
- a state, which is dynamic and fluctuating
- modifiable
- influenced by communication style
Our job is to elicit and reinforce patient
motivation for change.
22Rapid Diffusion Into Health CareSettings
23Motivational Interviewing Practice Basics
- Spirit, Principles, Micro-skills
24MI Spirit
- A way of being with patients which is
- Collaborative
- Evocative
- Respectful of autonomy
25Collaboration(not confrontation)
- Developing a partnership in which the patients
expertise, perspectives, and input is central to
the consultation - Fostering and encouraging power sharing in the
interaction
26Evocation(not education)
- The resources and motivation for change reside
within the patient - Motivation is enhanced by eliciting and drawing
on the patients own perceptions, experiences,
and goals - Ask key open ended questions
27Autonomy(not authority)
- Respecting the patients 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
28Spirit 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.
29Spirit 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.
30What 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)
31Four Guiding MI Principles
- Resist the righting reflex
- If a patient is ambivalent about change and the
clinician champions the side of change
32Four Guiding MI Principles
- Understand your patients 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.
33Four Guiding MI Principles
- Listen to your patient
- When it comes to behavior change, the answers
most likely lie within the patient, and finding
them requires some listening
34Four Guiding MI Principles
- 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.
35Core MI Skills (OARS)
- Asking
- Listening
- Affirming
36Asking
- Use of open ended questions allows the patient to
convey more information - Encourages engagement
- Opens the door for exploration
37Closed 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 havent you tried this exercise?
- Are you refusing treatment?
- Do you have a follow up appointment scheduled?
38Open-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
39Open-Ended Questions
- Exercise
- Turning closed-ended questions into
- open-ended ones
40Open-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
41Affirmations
- What is an affirmation?
- Compliments, statements of appreciation and
understanding - Praise positive behaviors
- Support the person as they describe difficult
situations
OARS
42Affirmations
- Examples
- I appreciate how hard it must have been for you
to decide to come here. You took a big step. - Ive 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.
43Affirmations
- Why affirm?
- Supports and promotes self-efficacy, prevents
discouragement - Builds rapport
- Reinforces open exploration (client talk)
- Caveat
- Must be done sincerely
OARS
44Express Empathy
- What is empathy?
- Reflects an accurate understanding
- Assume the persons perspectives are
understandable, comprehensible, and valid - Seek to understand the persons feelings and
perspectives without judging
45Express Empathy
- Empathy is distinct from
- Agreement
- Warmth
- Approval or praise
- Reassurance, sympathy, or consolation
- Advocacy
46Express 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 persons unique
perspective, feelings, and values which make up
the material we need to facilitate change
47Express Empathy
- Tips
- Good eye contact
- Responsive facial expression
- Body orientation
- Verbal and non-verbal encouragers
- Reflective listening/asking clarifying questions
- Avoid expressing doubt/passing judgment
48Empathy 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
49The Bottom Line on Empathy
- Ambivalence is normal
- Our acceptance facilitates change
- Skillful reflective listening is fundamental to
expressing empathy - - Miller and Rollnick, 2002
50Reflective Listening
OARS
51Listening
- 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
its a complex skill
52Reflective Listening
- Reflective listening is a way of checking rather
than assuming that you know what is meant. - (Miller and Rollnick, 2002)
OARS
53Reflective 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
54Reflective 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
55Learning 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
56Thinking Reflectively
- Exercise
- Split up into triads (1-speaker) (2-listeners).
- Each person will take a turn being a speaker.
- Each person will share a personal statement
- One thing I like about myself is
- (e.g., I am organized. I am creative.)
- The listeners respond with Do you mean that..
(generate at least 5 for each). - The speaker responds with only yes/no.
57Reflective 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
58Reflections 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...
59Reflections Are Statements
- Question
- Youre thinking about stopping? (inflection goes
up) - Versus a statement
- Youre thinking about stopping. (inflection goes
down)
60Reflective Listening
- Exercise
- Split up into triads (1-speaker) (2-listeners).
- Each person will take a turn being a speaker.
- Each person will share a personal statement
- One thing I like about myself is
- OR
- One thing about myself Id like to change is
- The listeners respond with reflections only.
- The speaker can respond with yes/no and
elaboration.
61Levels 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
62Not Reflective Listening
- Communication Roadblocks
- Ordering, directing, commanding
- Warning, cautioning, threatening
- Giving advice, making suggestions, providing
solutions - Persuading with logic, arguing, lecturing
- Telling what to do preaching
- Disagreeing, judging, criticizing, blaming
63Not Reflective Listening
- Agreeing, approving, praising
- Shaming, ridiculing, blaming
- Interpreting or analyzing, also labeling
- Reassuring, sympathizing, consoling
- Questioning, probing
- Withdrawing, distracting, humoring, changing the
subject
64Summaries
- 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
65Summarizing
- Exercise 3(part 1)
- Choose a partner.
- Speaker for 90 seconds talk about a habit,
behavior, situation you are thinking about
changing. - Listener listen only and then give a summary of
what youve been told. - Change roles and repeat.
66Summarizing
- Exercise (part 2)
- Change partners.
- Speaker once again tell your story for 90
seconds w/out interruption. - Listener listen only and then give a summary,
but this time include what you think is the
underlying meaning, feeling, dilemma in the
story. - Change roles and repeat.
67Listen For Change Talk
- D?A?R?N?C?A?T 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
68Affirming
- Supports patient self-efficacy
- Emphasize patient strengths
- Notice and appreciate positive action
- Genuineness is critical
69Affirmations 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
youre in.) - A compliment
- (Thank you for all your hard work today.)
70Theoretical Framework ofMotivational Interviewing
- Readiness to Change
- 1. Precontemplation not yet considering change
- 2. Contemplation evaluating reasons for and
against change - 3. Preparation planning for change
- 4. Action making the identified change
- 5. Maintenance working to sustain changes
71Experiential Exercise 4 The Persuasion Exercise
72How Do We Assist Others to Change?
- Exercise has 2 parts
- Use Persuasion
- Use Motivational Interviewing
- Reverse roles answer same questions
73Lets see if it worksPersuasion 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!
74Exercise Part 3 Now Lets TryUsing MI
- Ask you partner to select a personal change
theyve have made in the past - What change did you make?
- How did you decide to make this change?
- What people or events influenced your decision?
- What steps did you take to make the change?
- What did you learn from the process?
75Exercise Part 3 Now Lets TryUsing MI
- Now, whats a new change youre considered now?
- What prompted you to look _at_ this issue now?
- How might you go about it in order to it,
succeed? - What are the 3 reasons to do it now?
- Summarize what you heard.
- Close by asking, what will you do next?
76Stages of Change
Precontemplation
Maintenance
Relapse
Contemplation
Action
Preparation - Determination
77Stages of Change Model
CONCEPT DEFINITION APPLICATION
PRE-CONTEMPLATION Not considering possibility of change. Does not feel there is a Problem. Goal Raise awareness. Task Inform and encourage. Validate lack of readiness.
CONTEMPLATION Thinking about change, in the near future. Goal Build motivation and Confidence. 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 of specific action steps, behavioral changes. Goal Implement the plan. Task Support self-efficacy.
MAINTENANCE Continuation of desirable actions, or repeating periodic recommended step(s). Goal Maintain change or new status quo. Task Identify strategies to prevent relapse.
78RememberReadiness to change is a state, not
a trait.
79Readiness Rulers
- A Precontemplation Stage Tool
80Readiness Rulers I-C-R
- Importance The willingness to change
- Confidence In ones ability to change
- Readiness A matter of priorities
Confidence
Readiness
Importance
81Importance Ruler
- On a scale of 1 to 10, how important is it for
you to make a change?
1 2 3 4 5 6 7 8 9 10
Not at all important Somewhat important Extremely Important
82Importance 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?
83Confidence Ruler
- On a scale of 1 to 10, how confident are you that
you could make a change if you wanted to?
1 2 3 4 5 6 7 8 9 10
Not at all confident Somewhat confident Extremely confident
84Confidence 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?
85Strategies 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
86Simplified Motivational Categories
Importance of Change Importance of Change
Confidence in Ability Low High
Low Group 1 Little interest in change dont think they could even if they wanted to. Group 2 Want to change, but dont 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.
87Readiness Ruler
- On a scale of 1 to 10, how ready are you to make
a change?
1 2 3 4 5 6 7 8 9 10
Not at all ready Somewhat ready Extremely Ready
88Readiness 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?
89Exercise 4 The Readiness Ruler Exercise
90Exercise 4Lets 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 youve learned about MI in the
next week? - How ready are you to start utilizing what youve
learned about MI in the next week
91Exercise 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
92Decisional Balance
- A Contemplation Stage Tool
93Decisional BalanceAn Explanatory Model Of
Behavior Change
- Highlights the individuals 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.
94Decisional Balance
Decisional Balance Worksheet (Fill in what you
are considering changing)
Good things about behavior Not so good things about behavior
Not so good things about changing behavior Good things about changing behavior
95Decisional Balance Sheet
Reasons for staying the same Reasons for making
a change
- 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.
96Decisional BalancingBenefits and Costs Worksheet
Costs Benefits
1. 1.
2. 2.
3. 3.
4. 4.
Costs Benefits
1. 1.
2. 2.
3. 3.
4. 4.
97Conducting a Decisional Balance Discussion
- Accept all answers. (Dont 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 clients
goals and values. - Review the costs and benefits.
98Exercise 5 The Decisional Balance Exercise
99Exercise 5 Decisional Balance
- Partners will take turns as helper helpee.
- Helper begins by asking helpee to identify
either - something I know I need to change am
considering or - something I feel 2 ways about
- Helper assists helpee in completing a decisional
balance - Helper processes decisional balance with helpee
using OARS
100Exercise 5 Decisional Balance
- Ask your partner to think of an area of their
life in which they have been contemplating making
a change. - For example
- Starting a diet or exercise program
- Going back to school
- Moving to a new home.
101Negotiating a Change Plan
- Patient sets a goal
- Have patient develop a menu of strategiesbrainsto
rm. - 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)
102Summary Benefits of Using MI
- Evidence-based
- Patient Centered
- Provides structure to the consultation
- Readily adaptable to health care settings
103What Do You Think?
- On a scale of 1 to 10, how important is it for
you to start using motivational interviewing in
your practice? - On a scale of 1 to 10, how confident are you to
start using motivational interviewing in your
practice? - On a scale of 1 to 10,how ready are you to start
using motivational interviewing in your practice?
104Thank You For Coming Learning About MI!Any
Questions?
105More 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
106Other Experiential Exercises
107Imagine 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 thats enough?
108Looking 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?
109Looking 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 dont change, how do think your
life will look?
110Motivation 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
111Strengthening Commitment
- Summarize patients 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?