Introduction to Motivational Interviewing

1. Introduction to Motivational Interviewing Nimi Singh, MD, MPH Division of Adolescent Health and Medicine University of Minnesota Amplatz Children’s Hospital (adapted from Kelly Lundberg, Ph.D. University of Utah)

2. Disclosure • I have no financial relationships to disclose • I will not be discussing off-label use of any medications

3. OUTLINE • What is Motivational Interviewing? • Stages of Change • Impact of the counselor/ health care provider • Principles of motivational interviewing • Philosophical approach • Specific methods • Resources/ References

4. Motivational Interviewing • Empathetic, patient-focused directive counseling style • Seeks to create conditions for positive behavioral change • Well-suited for brief clinical encounters • Evidence-based (>200 clinical trials, both adults and adolescents) (grounded in theory, verifiable, generalizable, delivered by wide range of health care practitioners)

5. Two Assumptions: 1. Motivation: due to interpersonal interaction (not just innate character trait) • Confrontation leads to resistance • Empathy and understanding lead to change 2. Ambivalence to change: normal and natural •Competing positive and negative feelings • Decision balance: pros and cons

6. Motivational Interviewing (con’t) • Counselor/ Health care provider: facilitator • “Client/ Patient: presents arguments for change • Counselor: • Listens for ambivalence in patient’s own words • Reflects back negative and positive aspects of behavior AND of changing behavior • Supports client self-efficacy: • Points out strengths • Points out previous successes • Acknowledges difficulties of making behavioral change • Avoids resistance by avoiding lecturing and arguing with patient

7. Stage of Change Theory • Prochaska and DiClemente (1992) • Pre-contemplation • Contemplation • Action • Maintenance • Relapse

8. PRE-CONTEMPLATION • Not even thinking about change

9. CONTEMPLATION • Wax and wane toward the idea of change • Often influenced by emotionally salient evens • Is the stage of ambivalence

10. ACTION • Ambivalence is gone • Actual working on the change

11. MAINTENANCE • “Losing weight is easy. I’ve done it hundreds of times.” • Behavior change takes repeated implementation of new life skills • Changes in the physiology of our brain takes even longer • This is often when services/ support are withdrawn

12. RELAPSE • Return to the previous behavior • Once there has been a lapse or relapse, the individual re-enters at either: • Pre-contemplation • Contemplation • Action

13. Counselor plays KEY role in influencing re-entry point! • Clients will experience shame even when there is no one blaming them • Have the conversation about how you, as a health care provider, would respond to a relapse prior to it happening • Call your clients when they don’t show for their appointment

14. Why we like working with patients in Action stage • Our tools fit well with their stage of change • They cooperate and typically do what we suggest • We tend not to experience anger, frustration and impatience • We tend to feel disappointment when they don’t show for their appointment

15. Why we DON’T like working with clients in Precontemplation or Contemplation • Our tools don’t work with their stage of change • They don’t do what we suggest • We tend to experience anger, frustration and/or impatience • We tend to feel relieved when they don’t show for their appointment • We feel impotent

16. So what do we tend to do? • Spend more time with clients who are in the action stage then those who are not • Use derogatory labels for those who are in the pre-contemplation or contemplation stage • Forget that ambivalence is normal • Train clients to lie to us • Shrug our shoulders and say, “I can’t help someone who doesn’t want to be helped.” • Shrug our shoulders and say, “I can’t help someone who doesn’t admit to having a problem.”

17. Who are our clients? • Most of the conventional health care tools we have are for individuals who are in the Action stage • It is estimated that 30% of patients who present to clinic for care are in the Action stage (varies depending on type of clinic) • We tend to overestimate the motivation of those who say they’re ready to change and underestimate the motivation of those who indicate no interest in change.

18. Motivational Interviewing is the treatment of choice for AMBIVALENCE

19. PRINCIPLES OF MOTIVATIONAL INTERVIEWING • Express empathy • Develop discrepancy • Roll with resistance • Don’t argue against it • Encourage elaboration of resistance • What makes it so hard? • What would help? • Allow silence • Support self-efficacy

20. PHILOSOPHICAL APPROACH OF MOTIVATIONAL INTERVIEWING • Respectful • Nonjudgmental • Reflective • Encourages “Change” talk from client

21. One of the biggest difference between MI techniques and other techniques is that the CLIENT is the one who verbalizes the need for change rather than the counselor

22. EIGHT METHODS OF EVOKING CHANGE TALK • Elaborating • Asking evocative questions • Using the “Importance ruler” • Querying extremes • Exploring decisional balance • Looking back • Looking forward • Exploring goals and values

23. ELABORATING • Understand your client’s world view • Tell me about your (behavior). When did it start? When did it become a problem for you/ for others? • “How do you feel about it?” • “What do you get out of (problem behavior)? • “How do you think it causes difficulties for you? • Express empathy • “I can see why this must be hard for you…” • Summarize ambivalence • Begin to develop discrepancy between the polarized urges • Examples • So on one hand…and on the other… • Part of your wants…And the other part…

24. ASKING EVOCATIVE QUESTIONS • Evoking an emotionally “charged”/ evocative response is important for change to take place • You know your question is evocative if the client has to think about his or her response • Tone of voice is exploratory, not critical • Examples • What if you choose to continue _____? • What if you choose to decrease/ stop _____?

25. USING THE “IMPORTANCE RULER” • Three parts: • First Part: • On a scale of 1 to 10, 10 being “absolutely yes” and 1 being “no way”, how motivated are you to ______? • Ten is always direction you want the change to go • Sometimes it’s necessary to exaggerate the extremes

26. USING THE IMPORTANCE RULLER • Second Part: • Whatever number they give you, select one or two numbers BELOW and ask: Why a 6 instead of a 4? • By choosing a number below, you are eliciting change talk from the client

27. USING THE IMPORTANCE RULER • Third Part: • Take a number or two above what they gave you and ask: What would it take to move you to a 7, not actually (changing the behavior), but a little more comfortable with the idea? • Be sure to elicit something the client has control over • Whatever the client tells you becomes the treatment plan.

28. USING THE IMPORTANCE RULER • Make sure the plan is something the client can actually accomplish • Work with the client exploring potential barriers to the plan and appropriate solutions • Set an appropriate time line for implementing the plan (client-directed, if at all possible) • Sometimes an appropriate plan is that the client will think about the issue.

29. USING THE IMPORTANCE RULER • Sometimes the issue is not importance or motivation, but confidence • This is often obvious when the client provides an 8 or 9 on the Importance Ruler and yet remains stuck

30. USING THE IMPORTANCE RULER • If you believe motivation has increased during a session, use the ruler again • Group Application: • Clients identify where they are on the ruler • Have the clients with low numbers ask the clients with higher numbers to reflect on how they got there • Have the clients with high numbers ask the clients with low numbers how they intend to move

31. QUERYING EXTREMES • Always target CURRENT behavior • Example • What’s the worst thing about it? • What’s the best thing about it?

32. EXPLORING DECISIONAL BALANCE • Always target CURRENT behavior • Elicit pros and cons • “What do you get out of (behavior)?” • “What problems does it cause?”

33. LOOKING BACK • Always target CURRENT behavior • Example: • When was the last time _____ really made you feel good/ better/ worked for you? • The phrase “really worked for you” refers to all aspects of life • If this elicits a poignant reply, your best response is SILENCE • HARD, for us health care providers • We’re TRAINED to fix and intervene…silence often feels like failure or inaction • Often can be a powerful therapeutic tool in that it can powerfully deepen the client’s insight into the issues at hand)

34. EXPLORING GOALS (LOOKING FORWARD) AND VALUES • Three Parts: • First Part: • What do you see yourself doing ___ months/ years from now ( or next year)? • Do not use with individuals who : • You suspect are potentially suicidal • Terminal

35. EXPLORING GOALS (LOOKING FORWARD) AND VALUES • Second Part: • What are your top three values and why? • Define a value if necessary • Always get three (never settle for “I don’t know” from clients)

36. EXPLORING GOALS (LOOKING FORWARD) AND VALUES • Third Part: • How do you think (current behavior) fits with these values? • Tone of Voice is exploratory, NOT critical • Best used following some discussion about the key issue to be changed • This technique alone has been correlated with change

37. It is CRITICAL to engage clients in treatment plan(especially adolescents!!!)

38. Giving information and advice • Ask for permission • Qualify honoring autonomy • “Of course, while I can only suggest, you’re ultimately the one to decide…” • Ask – Provide – Ask • “….what do you think of that? Do you think that would work for you? Why? Why not?” • For suggestions, offer several, not one (otherwise it looks like the “right” answer)

39. Remember • Stress physiology is often driving “problem behavior” • Make sure you/ someone on health care team is exploring stress reduction techniques with client • When stress is managed in a more healthy, pro-social way, need for problem behavior diminishes

40. Resources • www.motivationalinterview.org • TIPS Manual (SAMHSA) • Project Match (NIAAA) • Motivational Interviewing (Miller and Rollnick)

41. References • Lundberg, KJ. “Introduction to motivational interviewing”; on-line Powerpoint presentation at: http://humanservices.slco.org/pdf/Long_MI_without_ASAM.pdf • Miller WR, Rollnick S. Motivational Interviewing: preparing people for change, 2nd ed. New York, NY: Guilford Press; 2002. • Miller WR, Rollnick S. What’s new since MI-2? Presentation in Stockholm, Sweden, June 2010 (at www.motivationalinterview.org • Prochaska, JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 1992;28:183. • Levy S, Knight JR. “Office-based management of adolescent substance use and abuse”, in Adolescent Health Care: a practical guide, 5th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2008.