Motivational Interviewing: Conversations that lead to Change

1. Motivational Interviewing: Conversations that lead to Change Carol DeFrancesco, MALS, RD Division of Health Promotion and Sports Medicine, OHSU defrance@ohsu.edu Special thanks to: Denise Ernst, Steve Berg-Smith and Bill Miller

2. Motivation changes with our style of interacting.

3. Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.

4. Why is Motivational Interviewing (MI) a method to consider? • MI has substantial evidence base supporting it’s effectiveness in facilitating change in behaviors that are hard to change • MI is effective with both psychological (behavior change) and physical outcomes (BMI, BP, BAC) • MI focuses the responsibility for change on the patient; encourages self-management and self-determination

5. The efficacy of MI –meta analyses • MI out performs traditional advice giving in 80% of studies • Effective in 10-20 minutes • More encounters over longer time period increase likelihood of an effect • Health professionals (MDs, RDs, RNs) can be as effective as psychologists or counselors

6. Profound Positive InfluenceDiscussion

7. The Spirit of MI • Evocation of person’s motivation, hopes, dreams, desires, values, goals, and abilities. • Partnershipwith the person; MI is done “for” and “with” a person and not “to” a person. • Acceptance including accurate understanding, affirmation, absolute worth of the person, and support of the person’s autonomy. • Compassion; active promotion of the person’s welfare and needs.

8. Self-Efficacy & Hope • A person must have hope • This is predictive of how they will do • A provider’s expectation is also predictive Bandura’s Theory of Self-Efficacy

9. Sitting on the fence of change

10. Cowboy from Klamath Falls People get defensive when their autonomy is threatened

11. What happens if you give advice to a person on the fence. . .Gas station story

12. Sustain Talk • The least desirable situation, from the standpoint of evoking motivation, is:when the health provider advocates for change while the patient argues against it

13. Most of us already have pro-change reasons of our own. These reasons are more persuasive than those of others. Bem’s Self-perception theory

14. Strength Cards and Break

15. Specific Skills: OARS OPEN Questions AFFIRMATIONS REFLECTIONS SUMMARIES

16. Reflective Statements • Statements not questions • Restates what patient says and selectively reinforces change talk • Puts the patient in a more active role when discussing behavior change

17. Reflective Statements • Pt: ‘I need to lose weight.’Provider: “Being overweight has got you concerned.” • Pt: ‘Healthy food is more expensive.’Provider: “You are wondering if you can afford to change your eating habits.” • Pt: “I know I could eat better.”Provider: • Pt: “I don’t have time to exercise.”Provider:

18. Forming Reflections with Strength cards: Large group activity then pairs

19. Why not simply ask questions (from Miller & Rollnick2013, pp 52-53) “Why respond with a statement . . . After all the listener is not sure if the guess is correct.” • A question requires a response; it places a demand on the other person • Pressing people with questions to explain themselves distances them from what they are experiencing – they step back to analyze and question what they have expressed. • A well formed reflection encourages continued exploration and minimizes defensiveness

20. Debrief Strength Activity

21. OARS OPEN Questions AFFIRMATIONS REFLECTIONS SUMMARIES

22. Questions that Evoke Change Talk (from Miller & Rollnick 2002) Category:Disadvantages of the status quo • What concerns you about _______? • What makes you think you need to do something about _______? • What hassles have you had in relation to your smoking (or other behavior)? • How has this stopped you from doing what you want to do in life? • What do you think will happen if you don’t change anything?

23. Questions that Evoke Change Talk(from Miller & Rollnick 2002) Category: Advantages of change • How would you like things to be different? • What would be the good things about ______? • What would you like your life to be like five years from now? • What are the main reasons you see for making a change? • What do you want?

24. Questions that Evoke Change Talk (from Miller & Rollnick 2002) Category: Optimism about change • If you decide to make a change, what would you do to be successful? • What do you think would work for you if you decide to change? • When else in your life have you made a significant change like this? How did you do it? • What personal strengths do you have that will help you succeed?

25. Questions that Evoke Change Talk (from Miller & Rollnick 2002) Category: Intention to change • What are you thinking about your smoking (eating habits, exercise) at this point? • What do you think you might do? • What would you be willing to try? • What do you want to have happen?

26. Affirmations & Self-affirmations • Emphasize a strength (What strengths do you have that will help you be successful?) • Appreciate a positive action (What is working for you?) • How are you keeping yourself healthy?

27. Summaries can: • Collect material that has been offered • So far you’ve expressed concern about your pacing, sleep, and options for pain medications. • Link something just said with something discussed earlier. • That sounds a bit like what you told me about that before when you were successful in changing. . . • Draw together what has happened and transition to a new task • Before I ask you the questions I mentioned earlier, let me summarize what you’ve told me so far, and see if I’ve missed anything important. You came in because you were feeling really sick, and it scared you . . . . . . . . .

28. Listening… • How to stop the talkers…. • Summarize and use a bridging statement • I’d like to shift gears… go back to something you mentioned… • Discuss time limitations • Give value to what you have heard • “We have talked about a lot of things today, if you had to pick on one to work on…”

29. OARS Batting Practice OPEN Questions AFFIRMATIONS REFLECTIONS SUMMARIES

30. Most of us already have pro-change reasons of our own. These reasons are more persuasive than those of others. Bem’s Self-perception theory

31. Sustain Talk • The least desirable situation, from the standpoint of evoking motivation, is:when the health provider advocates for change while the patient argues against it

32. Listening for Change Talk Levels: Preparatory - I need to, I’ve been thinking about, I’ll try, I want to, I can Commitment - I will, I am going to, I have already started

33. Change Talk Levels Court room oath: “Do you swear to tell the truth, the whole truth and nothing but the truth, so help you God?” Wedding Vows “Do you Jen take Bill to be your husband . . . Will you love him and honor him, in sickness and in health . . . ?”

34. Four Foundational Processes Planning Evoking Focusing Engaging

35. Demonstration

36. Conversation Roadmap Set the stage and engage “I would like to spend about 10 minutes talking about your eating habit goals, would that be OK?” “What are you already doing to eat healthy?” “What do you notice . . .” Decide where to focus “There are a number of things that go in to healthy eating: more vegetables and fruits, less junk or sugar, regular meals . . Where do you feel ready to make a change?”

37. Healthy Eating Ideas • Eat out less Eat regular meals Cut back on sugar Increase fruits & vegetables Drink less soda Shop for food regularly

38. Conversation Roadmap Evoke deeper reasons “Why did you choose . . .?” “Why else would this be a good thing?” Plan when client is ready “What are you willing to try?” Summarize and Close “Let me see if I got it all . . .What are you ready to commit to in the next couple weeks?”

39. Your turn: Groups of 3handout

40. Debrief: Speakers first: “What seemed to further your change process?”

41. Debrief: Listeners What did you notice?

42. “It is through the power of our listening, not the wisdom of our words that we are able to affect the most change” Carl Rogers